Health Care Systems and Reimbursement KNH 413 MNT II Health Care Systems and Reimbursement

Overview Health Care Facilities in the U.S. Preventive & Primary Health Care Services Secondary & Tertiary Care Restorative Care Long-Term Care

Health Insurance © 2007 Thomson - Wadsworth

© 2007 Thomson - Wadsworth

Providers of Public Insurance Centers of Medicare & Medicaid Services Department of Veterans Affairs Public Health Services Indian Health Service Department of Defense Civilian Health & Medical Program of the Uniformed Services CHAMPUS Public hospitals & community health centers State & local public health programs

Medicare 1965 Title XVIII of Social Security Act Administered by CMS of Department of Health & Human Services

Eligibility 65 years of age or older Any age with end-stage renal disease Eligible for Social Security or Railroad Retirement Board disability benefits up to 24 months Medicare-covered government employment prior to retirement

Medicare Part A Hospital Insurance Inpatient hospital, skilled nursing facility, & some home health Deductibles & coinsurance fees Hospital inpatient charges reimbursed according to prospective payment system (PPS) Diagnosis-related groups (DRGs)

Medicare Part B Medical insurance Optional program Provides benefits for Eligible physician services Outpatient hospital services Certain home health services Durable medical equipment Nutrition Medical Nutrition Therapy Current procedural terminology (CMT) Enrolled Medicare MNT providers bill for Diabetes mellitus Nondialysis kidney disease Post-kidney transplant

Medicare savings after 3 years of reimbursement of nutrition services © 2007 Thomson - Wadsworth

Coverage Gaps Prescription drug coverage Skilled nursing & long-term institutional care > 100 days Medicare Modernization Act of 2003 Optional coverage Drug discount cards/prescription drug plans Additional preventive benefits Medigap Policy Supplemental policy from private insurance companies

Medicaid Entitlement program Joint state & federal program 1965 Title XIX of the Social Security Act

Eligibility Low incomes Certain pregnant women & children with low incomes Older adults, the blind & people with disabilities Members of families with dependent children in which one parent is absent, incapacitated or unemployed

SCHIP State Children’s Health Insurance Program Title XXI in the Balanced Budget Act of 1997 Children of working families with incomes too high to qualify for Medicaid but too low to afford private health insurance

Coverage Inpatient & outpatient hospital services Physicians’ surgical & medical services Laboratory X-ray services Well baby/child care services

Percentage of Uninsured in U.S.

Elderly needing long-term care

Health Care Reform Success of health care system Challenges Cost Quality Access Challenges Accessible to all Contain costs Provide nursing home care Ensure that Medicare & Medicaid can serve eligible people

© 2007 Thomson - Wadsworth

National health expenditures in billions of dollars, 1960-2002 © 2007 Thomson - Wadsworth

© 2007 Thomson - Wadsworth