Public Insurance- Professional Practice
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| What are categorical programs? | Benefits are designed for defined categories of people
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| Three main public health insurance programs | Medicare
Medicaid
Children's Health Insurance Program (CHIP)
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| 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
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| 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)
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| In 2010, what act expanded gov't HC even more? | ACA of 2010
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| 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
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| 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
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| WPS Coverage- LCD's | Local Coverage Determination
Coverage policies pertaining to services/items not addressed in NCDs
Coding & utilization guidelines
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| 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
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| What are NCDs? | National Coverage Determination
Originate from CMS & apply to all Medicare jurisdictions
NCD = CMS
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| 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
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| 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
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| 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
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| Services not covered by Medicare | Vision
Eyeglasses
Dental care
Hearing aids
Many long-term care services
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| Public Financing- What is Medigap? | Private insurance used to cover gaps in Medicare
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| 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
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| Medicare Part A covers: | IP services
Short-term convalescence & rehab in SNF
Home Health
Hospice
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| 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
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| 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
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| 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
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| 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
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| Home Health Benefits of Part A | Patient must be homebound AND
require intermittent or part-time skilled nursing care or rehab care
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| Hospice Benefit of Part A | Pt must be temrinally ill (not anticipated to live >6 months)
Only a token co-pay is req'd
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| 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
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| Part B- what does pt have to pay for services? | An annual deductible must be paid
80:20 co-insurance
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| 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
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| 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)
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| 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
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| Donut Hole | MC doens't pay until person has paid 100% to $4,700, then MC starts paying 95%
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| Deductible- Part D | Drug costs- $320
MC Pays- None
Beneficiary Pays- $320
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| Initial Coverage- Part D | Drug Costs- $321-2,930
MC Pays- 75% up to $1,957.50
Beneficiary Pays- 25% up to $652.50
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| 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)
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| 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
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| 4 Primary Processes of MC Quality Control | Report cards
Provider certification
Utilization review (looking at medical records)
Oversight by PROs (peer review orgs)
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| 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
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| 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
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| 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
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