Managed Markets Monday: Medicare, Medicaid and Health Care Reform

Medicare and MedicaidAn Overview

Medicare and Medicaid

• Government funded health programs for United States citizens who would be otherwise uninsured

• Created in July 1965 as part of President Lyndon Johnson’s “Great Society” reforms

• Programs have expanded to cover gaps in the private insurance system

• Account for approximately $800 billion in federal spending per year

www.kff.org/medicaid/upload/7334-04.pdf

www.kff.org/medicare/upload/7615-03.pdf

Comparative overview

Medicare Medicaid

For those 65 and over or those with certain disabilities

For citizens below a certain income threshold or those with certain disabilities

Financed through social security taxes and beneficiary premiums

Funded in cooperation between state and federal governments

Coverage benefits depend on which program one is enrolled in, prescription drug costs are not covered by basic Medicare

Many coverage benefits are federally mandated, but some (including prescription drug benefits) are determined by state

www.nls/prg/conf/medicare-medicaid.htm

Medicare

What is Medicare?

• A government funded health insurance program for people age 65 or older and people under 65 with certain disabilities or end-stage renal disease

• Citizens are immediately eligible for Medicare when they reach age 65 if payroll taxes were contributed to Medicare throughout their working life

• Covers approximately 45 million Americans• On average, half of enrollees’ health care costs are covered by

Medicare


What does Medicare cover?

Medicare Part A Covers

• Inpatient care in hospitals• Inpatient care in nursing facilities • Hospice care• Some home health care

Medicare Part B Covers

• Outpatient care• Physical and occupational therapy• Doctor’s services• Drugs incident to a physicians visit

Medicare Part C Covers Medicare Part D Covers

• Access to a plan from a private health insurance program approved by Medicare (Medicare Advantage Program)

• Prescription drug costs (offered on a state-by-state basis, must enroll in Medicare advantage plan)

www.ssa.gov/pgm/medicare.htm


*Medicare is divided into 4 parts

Summary of government payers

• Elderly• Disabled

• Poor• Young• Some

disabilities

• If you are elderly or disabled and poor or young

Medicare Medicaid Duel eligible

How is Medicare financed?

Part A Funded through a tax on the earnings of employers and their employees

Part B Funded by government revenues and premiums from higher-income beneficiaries

Part C Under Parts A, B, and D, and is therefore not funded separately

Part D Funded through government revenues and premiums from higher income beneficiaries

www.nls.org/conf/medicare-medicaid.htm


Medicaid

What is Medicaid?

• A health insurance program operated by the state for low-income citizens, those with physical or mental disabilities, and seniors

• Covers approximately 60 million Americans including more than 1 in 4 children– Covers more people than any other private or public insurance program– Largest provider of coverage for long-term care; covers the majority of nursing home

residents

• Enrollment– Greatly increased since the recent economic downturn– Grows at an average annual rate of 4.2%


www.medicaid.gov

What does Medicaid cover?

Federally Mandated Services• Hospital services• Physician’s services• Family planning services• Screening and x-ray services• Nursing home facilities • Some home health care• Transportation and translation

services

State Optional Services• Prescription drugs• Dental and vision services• Rehabilitation and physical therapy • Hospice services• Inpatient psychiatric services

www.healthcare.gov/using-insurance/low-cost-care/medicaid#cover


How is Medicaid financed?

• Funded through a partnership between state and Federal governments

• Federal government matches state Medicaid spending – The amount of funds matched depends on the state’s per capita income, with poorer

states receiving more federal money

www.nls.org/conf/medicare-medicaid.htm


Medicare, Medicaid, and Health Care Reform

Effects of Reform on Medicare

• Coverage gap in Medicare Part D will be eliminated to ensure enrollees have access to affordable prescription drugs

• Cost sharing for preventative care and screenings will be eliminated• Funding to reduce Medicare fraud will be increased• National standards of quality and safety will be established to improve

overall care• Long-term care will be more affordable• Life of the Medicare Trust Fund will be extended to reduce chance of

bankruptcy

www.healthreform.gov/reports/medicare/medicare.pdf

Effects of reform on Medicaid

• Eligibility to qualify for Medicaid will be expanded to include a substantially larger group of low-income citizens on a state-by-state basis – Federal government will pay all costs of the expansion beginning in 2014– To accommodate the expansion, enrollment will be simplified and quality of care

available under Medicaid will be improved

www.cnn.com/2102/07/05/opinion/carroll-mediciad-expansion/index.html

Works referenced

• http://www.ssa.gov/pgm/medicare.htm• http://www.healthreform.gov/reports/medicare/medicare.pdf• http://www.healthcare.gov/using-insurance/low-cost-care/medicaid• http://www.cnn.com/2012/07/05/opinion/carroll-medicaid-expansion/

index.html• http://www.kff.org/medicaid/upload/7334-04.pdf• http://www.kff.org/medicare/upload/7615-03.pdf• http://www.nls.org/conf/medicare-medicaid.htm

www.cnn.com/2102/07/05/opinion/carroll-mediciad-expansion/index.html

Managed Markets Monday: Medicare, Medicaid and Health Care Reform

Health & Medicine

Transcript of Managed Markets Monday: Medicare, Medicaid and Health Care Reform