Government Payer Types: Medicare, Medicaid, and Military Programs

Comprehensive vocabulary flashcards covering the major federal and state public healthcare payer programs, benefit designs, eligibility criteria, and administrative trust funds discussed in Harrington's Health Care Finance lecture.

Title XVIII of the Social Security Act

The federal legislation that originated Medicare, originally designated as Health Insurance for the Aged and Disabled to provide health coverage for individuals over the age of $65$.

Medicare Part A

A premium-free Hospital Insurance (HI) plan covering inpatient hospital care, skilled nursing facilities, long-term care hospitals, hospice, and home health care for individuals aged $65$ and older or qualified disabled individuals on Social Security/Railroad Retirement for at least $24\text{ months}$.

Federal Hospital Trust Fund

The fund financed through payroll tax contributions from employees, employers, and self-employed individuals used solely to pay Medicare Part A insurance benefits and administrative expenses.

Benefit Period (Medicare Part A Inpatient)

A period of care that begins upon hospital admission and ends when the beneficiary has been discharged from inpatient or skilled nursing care for at least $60$ consecutive days, allowing for up to $90\text{ days}$ of covered care per period.

Lifetime Reserve Days

A pool of $60$ additional days of inpatient hospital care that Medicare provides for a beneficiary to use over their lifetime when a hospital stay exceeds $90\text{ days}$ in a single benefit period, requiring a daily coinsurance payment.

Skilled Nursing Facility (SNF) Benefit Limit

Medicare Part A coverage limited to $100\text{ days}$ per benefit period for patients requiring a skilled level of care, with days $1\text{ to }20$ covered at no coinsurance and days $21\text{ to }100$ subject to a daily coinsurance.

Homebound Status

A qualification condition for Medicare home health care certified by a physician; patients qualify even if they leave home to receive medical care in adult day care, outpatient kidney dialysis, or outpatient chemotherapy and radiation therapy.

Low Utilization Payment Adjustment (LUPA)

A home health payment adjustment applied when an agency provides $4$ or fewer visits within a $60\text{-day}$ episode, reimbursing care on a per-visit basis by discipline rather than the full episode rate.

Partial Episode Payment (PEP)

A home health care payment adjustment made when a beneficiary elects to transfer between agencies or is discharged and readmitted to the same agency during the same $60\text{-day}$ plan of care episode.

Hospice Care (Medicare Part A)

A benefit program for beneficiaries certified by a physician as terminally ill with a life expectancy of $6\text{ months}$ or less, who choose comfort-focused palliative care over curative disease treatment.

Respite Care (Hospice)

Short-term inpatient hospice care provided to give family caregivers a break, for which the Medicare beneficiary is responsible for a coinsurance payment of up to $5\%$.

Medicare Part B

A voluntary Supplementary Medical Insurance (SMI) plan requiring beneficiary monthly premiums and annual deductibles, covering medically necessary physician services, outpatient care, DME, clinical research, ambulance services, and preventative screenings.

Federal Supplementary Medical Trust Fund

A separate trust account funded through voluntary monthly premiums paid by beneficiaries to finance Medicare Part B benefits and associated administrative costs.

Medicare Part C (Medicare Advantage)

Private managed care plans (such as HMOs and PSOs) that replace traditional Medicare Parts A and B (excluding hospice) and often offer additional benefits like vision, dental, and hearing coverage.

Medicare Part D

A voluntary prescription drug plan operated through private insurers that subsidizes the cost of FDA-approved prescription medications and biologicals not covered by Parts A and B.

Medigap

Private supplemental health insurance policies purchased by beneficiaries to cover out-of-pocket costs and gaps not covered under traditional Medicare Part A and Part B, such as deductibles and copayments.

Title XIX of the Social Security Act

The federal legislation establishing Medicaid, a jointly funded federal-state medical assistance program providing coverage to qualified low-income and medically needy populations.

Payer of Last Resort

The statutory requirement that Medicaid only pays claims after all other primary health insurance coverages, including Medicare and private health insurance plans, have processed payment.

Children's Health Insurance Program (CHIP)

A program created under the Balanced Budget Act of 1997 that provides federal matching funds to states to provide health insurance to uninsured, low-income children in families typically earning below $200\%$ of the Federal Poverty Level who do not qualify for Medicaid.

Programs of All-Inclusive Care for the Elderly (PACE)

A comprehensive managed-care program using an interdisciplinary team approach to deliver complete medical and social services to frail seniors aged $55$ and older who qualify for nursing facility care but reside in the community.

Temporary Assistance for Needy Families (TANF)

A federal block grant program that replaced Aid to Families with Dependent Children (AFDC) to grant states financial flexibility to provide monthly cash assistance to low-income families with dependent children.

TRICARE Prime

A military managed-care health insurance plan offered by the Department of Defense to active duty members and families, featuring an assigned Primary Care Manager (PCM) and zero out-of-pocket costs.

TRICARE For Life

A worldwide secondary health benefit plan for military retirees and family members of Medicare age who are enrolled in both Medicare Part A and Part B.

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs; a healthcare cost-sharing program for spouses and dependent children of veterans who are permanently and totally service-disabled or who died from service-related conditions.

Federal Employees Compensation Act (FECA)

The federal statute establishing workers' compensation benefits, medical care, and wage replacement for federal civilian employees injured on the job or suffering from occupational illnesses.

Indian Health Service (IHS)

An operating division within the federal government responsible for providing comprehensive, culturally acceptable personal and public healthcare services to American Indians and Alaska Natives.