Medicare Overview

  • Medicare provides HC coverage for:
    • Elderly
    • Disabled
    • People with end stage renal disease
  • Medicare is administered by the federal government.
  • Medicare Part A
    • Pays hospitals, skilled nursing facilities, home health care and hospice
    • Hospital insurance (inpatient)
    • Paid by payroll taxes (must pay in for 10 years)
    • Automatic enrollment
  • Medicare Part B
    • Pays physician, outpatient hospital, and others not covered in part A
    • Supplemental Medical Insurance
    • Paid by premiums from recipients (~$100/mo), individuals making more than $150,000/year pay $160/mo
    • $135/year deductible
  • Medigap
    • Medicare Part A supplemental insurance
    • Also known as Medicare select  (Medicare Advantage)  (Medicare Part C)
    • Operates like a managed care organization in that you must use a network or preferred provider
  • Medicare fiscal intermediaries-
    • Manage funds, make payments, & account for funds on behalf of the government
    • Perform administrative services (pay the bills, keep the records)
  • Medicare provides HC coverage for:
    • Elderly
    • Disabled
    • People with end stage renal disease
  • Medicare Part A
    • Pays hospitals, skilled nursing facilities, home health care and hospice
    • Hospital insurance (inpatient)
    • Paid by payroll taxes (must pay in for 10 years)
    • Automatic enrollment
  • Medicare Part A covers home health care, hospitalization, skilled nursing
    • Doesn’t cover infusion therapies (TPN or hyperal)
  • Medicare Part B
    • Pays physician, outpatient hospital, and others not covered in part A
    • Supplemental Medical Insurance
    • Paid by premiums from recipients (~$100/mo), individuals making more than $150,000/year pay $160/mo
    • $135/year deductible
  • Medigap
    • Medicare Part A supplemental insurance
    • Also known as Medicare select  (Medicare Advantage)  (Medicare Part C)
    • Operates like a managed care organization in that you must use a network or preferred provider
    • Medicare part A- covers in-patient services in hospital, can include cost sharing
      • Medigap- supplemental insurance for medicare part A (generally pays for all cost sharing other than what medicare covers)
  • Medicare fiscal intermediaries-
    • Manage funds, make payments, & account for funds on behalf of the government
    • Perform administrative services (pay the bills, keep the records)
  • Medicare PPS (prospective payment system) beginning in 1983 for hospitals
    • Payment determined in advance based on patient diagnosis
    • DRG’s created & hospital is paid a fixed amount (flat rate) for each DRG
    • Hospital has financial incentive to dismiss patients as soon as possible
    • Patient recovers at home, not at hospital
    • Patients bill of rights act of 1998 made it required for formularies to have this exception process.
  • Medicare part A- covers in-patient services in hospital, can include cost sharing
    • Medigap- supplemental insurance for medicare part A (generally pays for all cost sharing other than what medicare covers)
  • Medicare is administered by the federal government.  Medicaid is administered by the state and federal governments together
  • Medicare Part A covers home health care, hospitalization, skilled nursing
    • Doesn’t cover infusion therapies (TPN or hyperal)
  • Reasons for growth in home health care:

                        Medicare PPS (prospective payment system) beginning in 1983 for hospitals

  • Payment determined in advance based on patient diagnosis
  • DRG’s created & hospital is paid a fixed amount (flat rate) for each DRG
  • Hospital has financial incentive to dismiss patients as soon as possible
  • Patient recovers at home, not at hospital

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