How do we pay for Healthcare? Sheryl Buckner PhD, RN, ANEF University of Oklahoma College of Nursing

Private Pay Concierge MDs

Insurance

Medicare http://kff.org/medicare/video/the-story-of-medicare-a-timeline/ 1965 Coverage Check: https://www.medicare.gov/coverage/your-medicare-coverage.html Part A Hospital care Skilled nursing facility care Nursing home care (as long as custodial care isn't the only care you need) Hospice Home health services Part B Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.   Clinical research   Ambulance services Durable medical equipment (DME) Mental health Inpatient Outpatient Partial hospitalization Getting a second opinion before surgery Limited outpatient prescription drugs Share widget - Select to show Subcategories Your Medicare coverage Your Medicare coverage choices What Part A covers What Part B covers What drug plans cover What Medicare health plans cover Preventive & screening services Find suppliers of medical equipment & supplies Find & compare doctors, hospitals, & other providers What's not covered by Part A & Part B?, current page What's not covered by Part A & Part B? Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or you're in a Medicare health plan that covers these services. Even if Medicare covers a service or item, you generally have to pay your deductible, coinsurance, and copayments. Some of the items and services that Medicare doesn't cover include: Long-term care (also called custodial care) What Medicare A/B do not cover Most dental care Eye examinations related to prescribing glasses Dentures Cosmetic surgery   Acupuncture   Hearing aids and exams for fitting them Routine foot care Medicare Part C What's a Medicare health plan? Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans that can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B benefits. Medicare Advantage Plans (HMO, PPO) Medicare Medical Savings Account (MSA) Plans Other Medicare health plans Medicare Cost Plans Demonstrations/Pilot Programs Programs of All-inclusive Care for the Elderly (PACE) Medication Therapy Management (MTM) programs for complex health needs Medicare Part D (drug coverage) Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment. A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these: Provide written notice to you at least 60 days prior to the date the change becomes effective. At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change. : Premium Yearly deductible Copayments or coinsurance Costs in the coverage gap Costs if you get Extra Help Costs if you pay a late enrollment penalty Your actual drug plan costs will vary depending on: The drugs you use The plan you choose Whether you go to a pharmacy in your plan's network Whether the drugs you use are on your plan's formulary   Whether you get Extra Help paying your Medicare Part D costs Look for specific Medicare drug plan costs, and then call the plans you're interested in to get more details. If you have limited income and resources, your state may help you pay for Part A and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.

Medicaid https://en.wikipedia.org/wiki/Medicaid & 1965—part of Social Security Act—creation of Medicaid States given money to develop their own programs Oklahoma’s Plan—Soonercare-- Medicaid eligibility programs—Advantage program Medicaid in the United States is a social health care program for families and individuals with low income and limited resources. The Health Insurance Association of America describes Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care".[1] Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states,[2] with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all currently do.[when?] Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid. The Patient Protection and Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards. https://en.wikipedia.org/wiki/Medicaid & http://okhca.org/individuals.aspx?id=52&menu=114&parts=11601_7453 & http://okhca.org/individuals.aspx?id=8143&terms=advantage

1980’s Problem with Medicare/ Private Insurance Little oversight Organizations developed for private insurance to monitor healthcare HMO PPO Laws enacted to provide oversight to Medicare and Physicians Medicare Millionaires HMO A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. PPO Preferred Provider In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network . You pay more if you use doctors, hospitals, and providers outside of the network.

What if there were no Medicare/Medicaid?

Why Healthcare Reform? http://kff.org/health-reform/video/health-reform-hits-main-street/

Affordable Care Act http://kff.org/health-reform/video/youtoons-obamacare-video/

What if there were no Affordable Care Act? http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/at-stake-what-aca-means-for-middle-class-families/index.html

Let’s Take a Quiz http://kff.org/quiz/health-reform-quiz/

Why are there so many systems, so much complexity and no real change in health outcomes?

What does the future hold? What is going on and where is it headed?

First, to Navigate the System Know the Course Know your coverage If multiple coverages, know your primary, know your secondary, know your tertiary Know who to call (see step above) and where to call if problems occur Know if you need to get a referral before seeking un-emergent assistance