1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. END