HPM 100 Medicare

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Medicare's History
Title XVIII of Social Security Act - July 30, 1965 Failed attempts to provide national health insurance (New Deal), framed as socialist/communist Truman Administration  ​​​​​​​Campaign promise of national health insurance  Advisors adopted incremental approach (gradualism)  Linked to social security, framed as "hospital" coverage vs comprehensive health coverage  Kerr-Mills 1960 cover indigent elederly but not enacted by all state, only covered 2% of population Hospital insurance for all Social Security beneficiaries following Blue Cross model  Voluntary insurance for physician services similar to existing health plans for fed employees

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Alphabet Soup
Part A =financed thru fed payroll tax from employee and employer Part b = voluntary & financed thru monthly premium ($134 -$428 per month), taxes, interest from trust fund Part C = a voluntary program (Medicare Advantage)  Part D = created in 2003 Medicare Modernization Act (MMA)
Part A & B enrollees to opt into commercial Managed Care plans (i.e. Secure Horizons, Humana GoldPlus )  Include HMO, PPO, or prepaid FFS plans Gov't provides higher rates to private insurers to make sure they stay in market 

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Who qualifies for Medicare
Designed to provide health care to elderly and disabled U.S. residents  Age 65 and over, must pay payroll tax (1.45%) on at least 10 years of income (40 work credits)  You can eanr up to 4 work credits per year, 1 work credit is equal to $1,220 of income  Permanently Disabled (less than 65 years old)  certified by SSI 2 years  End Stage Renal Disease
Everyone gets Part A Free with 40 work credits  People w/ partial work credit can buy-in for an added premium Part B, C, and D are voluntary and require additional premiums

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Who does Medicare Cover?
disabled ages 19-64  Ages 6

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Distribution of Federal Outlays, 2014

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What does Medicare cover?
Medicare benefit package is outdated  similar to "major medical" plans that purchased by employers and consumers in the 1969s No pharmacy benefit until 2003 (part D) Part A - inpatient hospital care  Part B - outpatient/physican office care  Part C - Medicare advantage (combination of A & B)  Part D - Prescription Drug Benefit 

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Part A covers:
90 days of inpatient care per benefit period + 60 lifetime reserve days  Benefit period starts 1st day of hospital care & ends 60 days after discharge 190 lifetime days of psychiatric inpatient care  100 days of post-hospital care per benefit period in a skilled-nursing facility  unlimited home health agency vists hospice care

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Part B covers
most physician services (except routine exams)  selected preventive services:  1 times wellness exam  screening blood tests for cardiovascular disease  diabetes screening tests  Clinical lab services home health care  outpatient hospital services  durable medical equipment  blood No cap on annual copayments - most medicare beneficiaries have supplemental insurance 

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Supplemental plans

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Kathleen Corpuz Week 7 Discussion Define the following terms in your own words long-term care, activities of daily living, skilled nursing and hospice care. Out of hospital care: medical and non-medical needs, require help for activities of daily living: toileting, bathing, eating/feeding, dressing, transferring for the everyday life Skilled nursing – specialized care, providing people with medical services the entire stay, physical operational therapist Hospice care – end of life interdisciplinary care: priests, nurse , prognosis of 6 months, treating the symptoms What LTC services are covered under Medicare? What services are not covered? How are the services not covered under Medicare typically financed for low, middle and high income persons? Skilled nursing: Medicare (Part A) 100 days, qualifying hospital in-patient care, coinsurance 21-100 days Medicaid program quality per state may suck, rates differ each state   Prepaid insurance will prepay for services, other option is out of pocket What are the main issues facing the LTC system in the U.S.? Discuss these issues. Women are treated unequally, one state another – facilities taking what insurance? Burden on families for continuity Inadequate financing of LTC – unpaid labor marganilized care Focus on high need patients for high reimbursement – but the whole goal is to keep them independent Dignified care at home but services out of pocket are a burden LTCSS – community based alternatives, for those who prefer at home so financial incentives are not aligned to these preferences Work force shortages for specialization with aides of specific care to specific populations – not compensated well, problem with baby boomers

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Medicaid - need to be poor (onset of mD disorder) so Supplemental security income  Medicade and Social security disability insurance - disabled population with a long work history even if they are not poor  but can be dual eligible if poor