Reimbursement Methodologies ch 4

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Government Sponsored Health Care Programs

characteristics of payers

• All commercial insurance companies are licensed and regulated by the state's Commissioners of Insurance, not by the federal government.
• May be non-profit (Blue Cross and Blue Shield - BCBS) or for-profit such as Aetna, CIGNA, Prudential, etc

Medicare

A nationwide health insurance plan enabled by Title XVIII of the Social Security Act for individuals with the following characteristics:
1 People aged 65 and older
2.Persons with permanent disability
3.End-stage renal disease

Part A Hospital Insurance

(compulsory enrollment financed from a trust fund funded by a contributory tax)
Beneficiary pays deductible and co-payments after certain periods of time
Pays for the following types of services:
• Hospital-based inpatient care
• Care received in a Skilled Nursing Facility
• Home health care
• Hospice care

Part B Voluntary Supplemental Medical Insurance

(About 95% of eligible people exercise voluntary enrollment and must therefore pay monthly premiums to receive this insurance. It pays the provider of care 80% of the Medicare allowed charge on services.)
- Beneficiary pays monthly premium plus annual deductible and copayments
Physician services Medical services Medical supplies
• Durable medical equipment that has been prescribed by a physician such as wheelchairs, walkers, catheters, etc.

Part C:Medicare Advantage (MMA 2003) Was Medicare + Choice (1997)

(The major drawback of participating in a Medicare Managed Care or Private Fee-for-Service Plan is that the beneficiary is limited to seeing network providers of care, whereas with the
Original Medicare Plan they can see any provider of care and still have Medicare pay for services)
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

1. Outpatient drug coverage provided by private prescription drug plans and Medicare Advantage
2. Beneficiaries pay monthly premium, deductible, and copayments

Medicaid Title XIX of the Social Security Act 1965

A federally-aided (2 to 1 matching funds), state-operated and administered program that provides medical benefits for certain low-income persons in need of health and medical care.
Administered by individual states:
• Determine eligibility, type, amount, durations, scope of covered services
• Calculate the rate of payment
• May offer a managed care option

( this program vary significantly by state unlike the medicare program.)

Medicaid Title XIX of the Social Security Act 1965Required coverage for

1. Low income families with children including Temporary Assistance for Needy Families (TANF)
2. Supplemental Security Income recipients
3. Infants born to Medicaid-eligible pregnant women
4. Children under the age of six whose family income is at or below 133 percent of the federal poverty level
5. Recipients of adoption assistance and foster care
6. Certain Medicare beneficiaries
7. Special protected groups

basic services medicaid must provide

• Hospital inpatient and outpatient
• Rural health clinic services
• Laboratory
• X-ray
• Skilled nursing care for people for age 21 and older
• Home health care
• Early periodic screening, detection, and treatment preventive services for children through age 21
• Physician services
• Family planning
• Nurse midwife services where permitted by state practice laws

CHIP Children's Health Insurance
Program 1

begun during the Clinton-Gore Administration by way of an Amendment to the Social Security Act - Title XXI, as part of the Balanced Budget Act of 1997. It enables states to insure children from working families with incomes too high to qualify for Medicaid but too low to afford
private health insurance through other programs. • Since its inception, CHIP has provided healthcare services for more than 40 million children

CHIP Children's Health Insurance
Program 2 Services:

1. Inpatient
2. Outpatient
3. Physician's surgical and medical
4. Lab and x-ray
5. Well-baby/child care services and immunizations

Medigap Supplementary insurance to cover items and services not covered by Medicare

1. Offered by various insurance providers
2. Must meet Federal guidelines

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

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

TRICARE (formerly CHAMPUS:
Civilian Health and Medical Program-Uniformed Services)

1. Active-duty members of the military and qualified family members
2. Activated guard or reserve members

TRICARE (formerly CHAMPUS:
OPTIONS

1. TRICARE Prime and Prime Remote-ADSM or ADFM
2. TRICARE Extra -ADFM

3. TRICARE Standard and Standard Overseas-ADFM
4. TRICARE Young Adult-ADFM
5. TRICARE Reserve and Retired Reserve-Qualified National Guard and Reserve members
6. TRICARE for Life- Secondary coverage for those eligible for Medicare

CHAMPVA Civilian Health and Medical Program Veterans Administration

1. Dependents and survivors of disabled veterans
2. Survivors of veterans who died of service-related conditions
3. Survivors of military personnel who died in the line of duty
• Treated for free at participating VA healthcare facilities

HIS Indian Health Service
American Indians, Alaska Natives

1. Preventive health services
2. Primary medical services (hospital and ambulatory care)
3. Community health services
4. Substance abuse treatment services
5. Rehabilitative services

Workers' compensation --Work-related injuries

Covers: Healthcare costs, Lost income
Legislated by individual states
• Set coverage, Can exclude certain workers

Federal Employee's Compensation Act

• Federal government employees
• Established in 1916 and
administered by the Office of Workers' Compensation Programs
Provides for
1. Medical benefits
2. Death benefits
3. Income benefits

Which program replaced the Aid to Families with dependent Children AFDC

CHIP Children's Health Insurance

What legislation made substantive change to Medicare Benefits, and how did they change?

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

three types of Medicaid recipients required for states to qualify for federal matching funds

Low income families with children including Temporary Assistance for Needy Families (TANF)
2. Supplemental Security Income recipients
3. Infants born to Medicaid-eligible pregnant women
4. Children under the age of six whose family income is at or below 133 percent of the federal poverty level
5. Recipients of adoption assistance and foster care
6. Certain Medicare beneficiaries
7. Special protected groups

How was the PACE venture designed to enhance the quality of life for 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

What is the target population of the state CHIP/Title XXI

It enables states to insure children from working families with incomes too high to qualify for Medicaid but too low to afford

Which TRICARE program is the most economical for military families, and why is it less expensive than other options ?

?TRICARE Standard and Standard Overseas-ADFM?

What program covers ZHC costs and lost income from work related injuries or illness of FEDERAL government employees?

Workers' compensation
Federal Employee's Compensation Act

Individuals who are eligible for Railroad Retirement disability or retirement benefits are INeligible for Medicare

False ? False they are Eligible for Social Security or Railroad Retirement Benefits

Individuals who are eligible may choose between TRICARE and CHAMPVA

False ? False CHAMPVA is Dependents and survivors of disabled veterans

In states having no mandated Workers' compensation fund, employers must purchase insurance from private carriers or provide self-insurance coverage?

True or False

What types of costs do Medigap policies cover?

cost shared expense , such as the deductibles and 20% of DME

Why is Medicaid coverage not identical in NJ Ca and Idaho?

states maintain a unique program adapted to state residents' needs and average income

when a CHAMPVA beneficiary reaches 65, Medicare is the primary payer and CHAMPVA becomes the secondary payer?

True CHAMPVA becomes the secondary payer when another secondary benefit is available

Services offered by the IHS include all but

Death benefits

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