Government Healthcare Flashcards
Medicare
Created in **1966, Title 18 **of the Social Security Act as Health Insurance for the Aged and Disabled.
Intended to finance medical care for persons 65 and older or disabled who are entitled to social security benefits.
Mandates hospital services through the conditions of participation (COPs) for hospitals.
Overseen by CMS
Medicare Part A
Covers inpatient hospital, skilled nursing, nursing home with skilled need, hospice and home health.
Medicare Part B
Covers physician, outpatient, ambulance, clinical research and mental health.
Medicare Part C
Is a managed care option to obtain coverage for Parts A and B and sometimes D through a private health plan such as an HMO or PPO.
Medicare Part D
Covers prescription drugs.
Medicare Advantage
- Created by the Balanced Budget Act of 1997.
- Option for Medicare enrollees and provided by PRIVATE INSURANCE PLANS.
- Provides many services normally received under traditional Medicare with additional benefits.
- Managed care plans, networks are based on plan contracts and may be narrow.
Secondary Medicare Insurance
Covers co-pays and other financial responsibilities not covered by traditional Medicare.
Medicaid
- Created in 1996, Title 19 of the Social Security Act.
- Finances health care of indigent and other special designated groups.
- Financed jointly by federal and state governments.
- Eligibility criteria vary from state to state and based on income, assets and dependents.
Managed Medicaid
- Focus on cost containment, improved access and quality of care.
- Provided many healthcare services a medicaid recipient would normally receive on a prepaid capitiated basis.
- May have narrow networks.
Tricare
- Military. Provides healthcare to Active Duty, National Guard/Reservists, Retirees and their families, survivors, and certain former spouses of military personnel.
- Affords civilian health benefits military personnel and their dependents.
- Provides access to high quality healthcare.
- Plan offers medical, dental, and special coverage by uniting the healthcare resources of the military with civilian networks of healthcare providers.
When is Medicare Coverage considered “Primary”?
- Age 65 or older and retired.
- Age 65 or older and covered under an employer plan with less than 20 employees.
- Age 65 or older and covered on spouse’s plan when spouse is working with less than 20 employees.
When is Medicare Coverage considered “Secondary”?
Age 65 or older and covered by employer with 20 or more employees
Age 65 or older, and covered on spouse’s plan with 20 or more employees.
Medicare Shared Savings Program
- A type of ACO that facilitates coordination and cooperation among providers.
- Like ACOs in structure (patient-centered, patient and provider share in care decisions, quality evaluated by established measures and is incentivized by sharing shaving it achieves for the Medicare program
- For Medicare Fee-For Service beneficiaries to eliminate fragmented care and obtain coordinated, high quality care.
Medicare Shared Savings Program PURPOSE
Improve outcomes and increase the value of care by providing better care for individuals, better health for populations and lower expenditures.
What is the eligibility criteria for Supplemental Security Income (SSI)
Need-based program for people ineligible for SSDI due to never working or not accumulating enough work credits. Must meet income and resource guidelines.
