Component 1: Introduction to Health Care and Public Health in the U.S. 1.4: Unit 4: Financing Health Care (Part 1) 1.4 d: Government Payment Programs

Government Payment Programs Medicare Created in 1965 as part of the Social Security Act Administered by the Centers for Medicare and Medicaid Services (CMS) 3 ways to qualify for Medicare Over 65 & eligible for Social Security Benefits Permanently disabled Has end-stage renal disease Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs Medicare Covered benefits- hospital care and physician services Part A is hospital insurance- covers inpatient hospital services, critical access hospitals and skilled nursing facilities Part A requires a deductible and copayments Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs Medicare Part B covers physician services, outpatient hospital care, and some services and supplies. Premium is $88.50 per month (2006) Individual pays deductible and copayment. The deductible was $124 in 2006 Part C- Medicare + Choice offered HMO providers Part D- coverage for prescriptions and preventive care Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs Medicare Uses a prospective payment system where the amount of the payment is determined before the patient receives services. Based on the Resource-Based Relative Value schedule that pays more for specialty services Medicare also limits the total amount of the payment Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) Medicaid Medicaid is a transfer program. It is funded by taxpayers’ income tax payments Medicaid is administered through CMS and at the state level Eligibility and coverage vary from state to state States must provide coverage to certain individuals to qualify for federal funds Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) Medicaid State’s Medicaid spending is matched by the federal government Two major eligibility groups are those in poverty and medically needy If eligible for TANF(Temporary Assistance for Needy Families) and Supplemental Social Security Income (SSI), then Medicaid eligible. Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) Medicaid Covered benefits- hospital and physician services (states must provide); pharmacy, dental, and eye care (states may provide); and abortions (state can’t provide) Medicaid provides fee-for-service reimbursement for providers, but most feel rates are too low. Providers do not have to accept Medicaid patients Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) State Children’s Health Insurance Program (SCHIP) SCHIP covers targeted low-income children whose parents do not qualify for Medicaid, but cannot afford health insurance In most states, this is a plan that is separate from Medicaid Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) Fraud and Abuse HIPAA legislation gave the government greater authority to investigate and punish fraud Civil penalties include large fines, criminal penalties include imprisonment Types of fraud Intentionally to obtain payments for which you are not entitled to receive Miscoding Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

Government Payment Programs (cont’d) Worker’s Compensation A government-administered program to provide health care benefits to employees who are injured on the job Designed to eliminate the need for an employee to sue the employer for negligence when the employee was injured in the workplace Workers file claims to the state Worker’s Compensation Commission or Board Component 1/Unit 4d Health IT Workforce Curriculum Version 1.0/Fall 2010

END