chaoter 2.6 - centers for medicare & medicaid services

us health insurance coverage

• 66.1% private insurance

• 35.5& public insurance - medicaid, medicare, departmeent of veterans affairs

types of reimbursement

• the money paid from the third party payer for health services

  • health insurance companies, MCOs, & government → third party payers

• retrospective

  • payment for services already rendered

  • used in fee-for-service models

• prospective

  • predetermined, fixed amount/cost based on care & conditions

  • includes capitated rate & per diem rate

  • used by MCOs, medicare, medicaid

coding systems

• international classification of diseases 11th revision

  • diagnoses & hospital inpatient procedures

• healthcare common procedures coding system

  • codes physician services & procedures

  • codes supplies, devices, equipment

medicare

• benefits for

  • individuals over 65

  • persons w disabilities who qualify for social security benefits

  • ppl w end-stage renal disease or amyotrophic lateral sclerosis

• considered an entitlement program

  • employees pay into program through wage deductions to receive benefits when eligible

major parts

• part a - fedgov

• covers hospitalizations, short stay SNF, some home health/hospice

  • no premium or out of pocket max

  • deductible & copay/coinsurance

  • funded through payroll taxes

• part b - fedgov

• covers doctor’s services, outpatient care, PT/OT, some home health

  • no out of pocket max

  • deductible, coinsurance, premium

  • funded through federal tax revenue, premiums & coinsurance

• part c - medicare advantage, replacement for the other plans

• covers prescription drugs, vision, & dental

  • replaces A & B through private insurer like MCO

  • must enroll in parts A & B first, and continue to pay part B premium

  • MCO will set own prices for cost sharing, must stay within MCO network

• part d - fedgov, must enroll

• covers prescription medications, provided through private insurance companies

  • no out of pocket max now, but will in 2025

  • premium, deductible, and copay/coinsurance

  • funded through federal tax revenue & premiums

medicare highlights

• out of pocket costs may be substanial

  • not all health services are covered w every plan

• if qualify may simultaneously enroll in medicaid based on income

• can use w employer-sponsored retiree insurance

• supplemental plans (medigap or medsup) can be purchased to cover fees (not for medicare part c/advantage enrollers)

• hospital readmissions reduction program

  • penalties for unplanned hospital readmissions within 30 days

  • used to evaluate performance & quality of care

medicaid & chip highlights

• considered a welfare program that provides low cost or free healthcare & social services to ppl w low income as defined by each state

• administered at state level w funding support & guidelines from federal government

• ACA expansion of medicaid/chip

  • increase in federally matched support to cover more ppl

  • focus on providing more primary/preventative services, behaviral health treatment, chronic disease services

• challenges

  • eligibility varies by state

  • not all providers or health systems participate in the medicaid program

  • reimbursement for services not as high as private insurance

• changes in 2025

  • new federal work requirement starting in jan 2027

    • upon application & enrollment, enrollee must provide documentation of work or exemption status

    • if unable, deemed non-compliant & disenrolled within 30 days

  • expected to change enrollment over the next 10 years