Government Involvement in Health Care - Medicare and Medicaid

1
Government Involvement in Health Care - Medicare
and Medicaid

• Craig A. Pedersen, R.Ph., Ph.D.
• School of Pharmacy
• Ohio State University
• and
• Mary Haven

2
ObjectivesMedicare 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

3
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.

4
Government Involvement in Health Care

• Part One

5
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 governments role?

6
Summary of Governments Major Health Care Roles
Source Jonass Health Care Delivery in the
United States, 1995, pg 325
7
Medicare
Fed Govt

• Title XVIII of the Social Security Act
• Federally defined and administered health care
  program for elderly (?65) and certain other
  groups (lt65, 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)

8
Medicare
Fed Govt

• 2 parts
• Part A (Hospital Insurance)
• Part B (Supplementary Medical Insurance)
• Plenty of Cost Sharing, so Medicare doesnt 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
• http//www.medicare.gov

9
Medicare - Part A
Fed Govt

• 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 91-150,476 day coinsurance or copay
• After 150 days, Medicare does not pay anything
• Covers
• Inpatient care
• Skilled nursing following hospitalization
• Home health care
• Hospice Care

10
Medicare - Part A
Fed Govt

• Covered Inpatient Expenses
• Semiprivate room (2-4 beds)
• Meals
• Nursing services
• ICU, CCU
• Drugs (inpatient only)
• Blood
• Lab and X-ray

• Medical Supplies
• Wheelchairs and other appliances
• Operating room, and recovery room costs
• Rehabilitation services (PT, OT, Speech
  pathology)
• Some hospice

11
Medicare - Part A
Fed Govt

• Services NOT covered
• Telephone
• Television
• Private duty nurse
• Private room
• Long-term care

12
Medicare - Part B
Fed Govt

• 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

13
Medicare - Part B
Fed Govt

• 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

14
Medicare - Part B
Fed Govt

• 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

15
Medicare - Part B
Fed Govt

• Covered Services (Update)
• Pneumococcal pneumonia vaccine
• Medical nutrition services with doctors 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

16
Medicare - Part B
Fed Govt

• Services NOT covered
• Routine Physical Exam and test associated with
  that visit, except for 1st 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

17
Medicare Health Plans
Medicare Advantage Plans
Original Plan Managed Care Plans HMO/PPO Private Fee for Service Plan
Costs (out of pocket to pt.) High Low to Medium Medium to High
Doctor Choice Widest Some Wide
Extra Benefits None Most (Prescrip. drugs, routine physicals, eye) Some (Foreign travel, extra days in hospital)
Convenience Varies Varies Varies
18
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 11-05 to 3-06

19
For More Information on Medicare Part D

• http//www.medicare.gov/PresDrugs

20
Government Involvement in Health Care

• This concludes Part One