Government Involvement in Health Care - Medicare and Medicaid

1. Government Involvement in Health Care - Medicare and Medicaid Craig A. Pedersen, R.Ph., Ph.D. School of Pharmacy Ohio State University and Mary Haven

2. ObjectivesMedicare and Medicaid • After viewing and listening to the Internet lectures, the student will be able to: • Distinguish between Medicare Part A and Medicare Part B • Explain to a group of senior citizens the importance of Medicare supplemental insurance to them

3. Objectives cont. • Compare and contrast the Medicare and Medicaid programs • Name the group which requires the largest expenditures of Medicaid dollars in Nebraska and the nation. • Name the group with the largest number of recipients of Medicaid in Nebraska and the nation.

4. Government Involvement in Health Care Part One

5. Government Involvement in Health Care • Government is a major force in health care • Spends more than 40% of all health care dollars • Employs over 1.6 million people to deliver HC • Regulates who may provide/practice • What is government’s role?

6. Summary of Governments’ Major Health Care Roles Source: Jonas’s Health Care Delivery in the United States, 1995, pg 325

7. Medicare Fed Govt • Title XVIII of the Social Security Act • Federally defined and administered health care program for elderly (65) and certain other groups (<65, end stage renal disease and disabled) • Disabled are a concern • 6 month waiting period • Consider AIDS (or other diseases) for example • No income limits as of 2006 (may change)

8. Medicare Fed Govt • 2 parts • Part A (Hospital Insurance) • Part B (Supplementary Medical Insurance) • Plenty of Cost Sharing, so Medicare doesn’t pay for everything • Everyone eligible for Medicare gets Part A • Option to purchase Part B (comes out of SS check) • Funded through 1.45% payroll tax on employee and employer • http://www.medicare.gov

9. Medicare - Part A Fed Govt • 150 Days per year are covered (partly) • From Days 1-60, $952 Deductible in 2006 • From Days 61-90, $238 day coinsurance in 2006 • From Days 91-150,$476 day coinsurance or copay • After 150 days, Medicare does not pay anything • Covers • Inpatient care • Skilled nursing following hospitalization • Home health care • Hospice Care

10. Covered Inpatient Expenses Semiprivate room (2-4 beds) Meals Nursing services ICU, CCU Drugs (inpatient only) Blood Lab and X-ray Medical Supplies Wheelchairs and other appliances Operating room, and recovery room costs Rehabilitation services (PT, OT, Speech pathology) Some hospice Medicare - Part A Fed Govt

11. Medicare - Part A Fed Govt • Services NOT covered • Telephone • Television • Private duty nurse • Private room • Long-term care

12. Medicare - Part B Fed Govt • Helps pay for physician services and out-patient services (LAB, X-ray, PT, etc.) • Does not cover care not necessary or not reasonable to a particular treatment or injury • Does not cover outpatient prescription drugs

13. Medicare - Part B Fed Govt • Cost: $88.50/month in 2006 (set at 25% of forecasted program costs) • $124 annual deductible • 20% coinsurance or copay • 50% copay for mental health care

14. Medicare - Part B Fed Govt • Covered Services (Provider must be Medicare approved) • Doctors’ services • Outpatient Hospitalization • Diagnostic tests (X-ray and lab) • Durable medical equipment • Physical Therapy, Occupational Therapy, Speech pathology (yearly caps, $1740 for PT/SLP and $1740 for OT) • Flu, and Hepatitis B vaccines

15. Medicare - Part B Fed Govt • Covered Services (Update) • Pneumococcal pneumonia vaccine • Medical nutrition services with doctor’s referral • Some preventive services • Bone mass measurements • Colorectal and prostate cancer screening • Mammography and PAP smears • Glaucoma screening • Diabetes self-management training and screening • Cardiovascular screening

16. Medicare - Part B Fed Govt • Services NOT covered • Routine Physical Exam and test associated with that visit, except for 1st visit within first 6 mos. • Routine foot and dental care • Exams for fitting eye glasses or hearing aids • Immunizations; except flu, Hep B, pneumococcal pneumonia • Prescription drugs • Cosmetic Surgery

17. Medicare Health Plans Medicare Advantage Plans

18. Medicare – Part D • Outpatient prescription drugs • Started January 1, 2006 • Benefit designs vary, all are private plans • Does not establish a standard Part D premium • Actual coverage is complicated • Initial open enrollment period: 11-05 to 3-06

19. For More Information on Medicare – Part D http://www.medicare.gov/#PresDrugs

20. Government Involvement in Health Care This concludes Part One