Government Involvement in Health Care - Medicare and Medicaid Craig A. Pedersen, R.Ph., Ph.D. School of Pharmacy Ohio State University and Mary Haven

Objectives Medicare and Medicaid After viewing and listening to the Internet lectures, the student will be able to: –Distinguish between Medicare Part A and Medicare Part B –Explain to a group of senior citizens the importance of Medicare supplemental insurance to them

Objectives cont. –Compare and contrast the Medicare and Medicaid programs –Name the group which requires the largest expenditures of Medicaid dollars in Nebraska and the nation. –Name the group with the largest number of recipients of Medicaid in Nebraska and the nation.

Government Involvement in Health Care Part One

Government Involvement in Health Care Government is a major force in health care –Spends more than 40% of all health care dollars –Employs over 1.6 million people to deliver HC –Regulates who may provide/practice What is government’s role?

Summary of Governments’ Major Health Care Roles Source: Jonas’s Health Care Delivery in the United States, 1995, pg 325

Fed Govt Medicare Title XVIII of the Social Security Act Federally defined and administered health care program for elderly (  65) and certain other groups (<65, end stage renal disease and disabled) Disabled are a concern –6 month waiting period –Consider AIDS (or other diseases) for example No income limits as of 2006 (may change)

Fed Govt Medicare 2 parts –Part A (Hospital Insurance) –Part B (Supplementary Medical Insurance) Plenty of Cost Sharing, so Medicare doesn’t pay for everything Everyone eligible for Medicare gets Part A Option to purchase Part B (comes out of SS check) Funded through 1.45% payroll tax on employee and employer

Fed Govt Medicare - Part A 150 Days per year are covered (partly) From Days 1-60, $952 Deductible in 2006 From Days 61-90, $238 day coinsurance in 2006 From Days ,$476 day coinsurance or copay After 150 days, Medicare does not pay anything Covers –Inpatient care –Skilled nursing following hospitalization –Home health care –Hospice Care

Medicare - Part A Covered Inpatient Expenses –Semiprivate room (2-4 beds) –Meals –Nursing services –ICU, CCU –Drugs (inpatient only) –Blood –Lab and X-ray Fed Govt –Medical Supplies –Wheelchairs and other appliances –Operating room, and recovery room costs –Rehabilitation services (PT, OT, Speech pathology) –Some hospice

Fed Govt Medicare - Part A Services NOT covered –Telephone –Television –Private duty nurse –Private room –Long-term care

Fed Govt Medicare - Part B Helps pay for physician services and out- patient services (LAB, X-ray, PT, etc.) Does not cover care not necessary or not reasonable to a particular treatment or injury Does not cover outpatient prescription drugs

Fed Govt Medicare - Part B Cost: $88.50/month in 2006 (set at 25% of forecasted program costs) $124 annual deductible 20% coinsurance or copay 50% copay for mental health care

Fed Govt Medicare - Part B Covered Services (Provider must be Medicare approved) –Doctors’ services –Outpatient Hospitalization –Diagnostic tests (X-ray and lab) –Durable medical equipment –Physical Therapy, Occupational Therapy, Speech pathology (yearly caps, $1740 for PT/SLP and $1740 for OT) –Flu, and Hepatitis B vaccines

Fed Govt Medicare - Part B Covered Services (Update) –Pneumococcal pneumonia vaccine –Medical nutrition services with doctor’s referral –Some preventive services Bone mass measurements Colorectal and prostate cancer screening Mammography and PAP smears Glaucoma screening Diabetes self-management training and screening Cardiovascular screening

Fed Govt Medicare - Part B Services NOT covered –Routine Physical Exam and test associated with that visit, except for 1 st visit within first 6 mos. –Routine foot and dental care –Exams for fitting eye glasses or hearing aids –Immunizations; except flu, Hep B, pneumococcal pneumonia –Prescription drugs –Cosmetic Surgery

Medicare Health Plans Original Plan Managed Care Plans HMO/PPO Private Fee for Service Plan Costs (out of pocket to pt.) HighLow to Medium Medium to High Doctor Choice WidestSomeWide Extra Benefits None Most (Prescrip. drugs, routine physicals, eye) Some (Foreign travel, extra days in hospital) ConvenienceVaries Medicare Advantage Plans

Medicare – Part D Outpatient prescription drugs Started January 1, 2006 Benefit designs vary, all are private plans Does not establish a standard Part D premium Actual coverage is complicated Initial open enrollment period: to 3- 06

For More Information on Medicare – Part D

Government Involvement in Health Care This concludes Part One