US Health CareNICOLE ANDERSON

11/7/2016MSN 603

DR TARRANT

Medicare • Part A-Hospital• Inpatient hospitalizations, Home health, Hospice, Skilled nursing facilities (not custodial or

long-term care)• Some may not pay a premium, if they have payroll deductions

• Part B- Medical• Physician appointments and outpatient hospital services

• May cover some services not covered by Part A• I.E. physical and occupational therapist

• Many pay a monthly premium

• Part C• Medicare Advantage program

• Part D• Prescription drugs not covered under part A and B

• Many pay a monthly premium

Medicaid• coverage for• pregnant women, • children under age 6 • families at or below the poverty level

• States must provide minimum set of benefits• Required to pay Medicare premiums• Deductibles and copayments

Reimbursement • Fee-for-service• Charge provided for each service• Submit claims to insurers for payment

• Physician/Clinician reimbursement (Under fee-for-service)• Codes are picked based on IDC-10 and then payment

levels are assigned

• Prospective payment systems (PPS)• Payment established based on diagnosis-related groups

• Bundled payments/Global payments• Providers paid a flat rate for an episode of care• Insurer is paid per member per month

Affordable Care ActACA

ACA-

Coverage

• Ends pre-existing conditions exclusion for children

• Young adults coverage

• Ends arbitrary withdrawals of insurances

• Right to appeal

Cost

• Ends lifetime limits on coverage

• Reviews premium increases• Companies must justify any rate

increase

• Getting more from your premium dollars

ACA- continued

Care• Covers preventive care• Patients choice of doctors• Ability to choose primary doctor

patients wants• Removes barriers to emergency

services• Ability to seek ER care at

hospital outside your network

Policy Influences• The influence of policy on this process and what that means

to the patients financial obligations. • The Accountable Care Act (ACA) emphasizes higher quality

care for low payments.• No reimbursement for hospital-acquired conditions and VBP• 30 readmissions for key diagnoses, HAC”s, lack of meaningful use

Patients with no insurance• Clinics treating these patients need to apply for federal

funding such as grants and donations• Patients need to have access to Medicare/Medicaid• It is not feasible for a clinic to stay open finically without

these options

References• @. (n.d.). Healthcare Costs: What Are HSAs, FSAs, HRAs, and

HDHPs? Retrieved November 01, 2016, from http://www.healthline.com/health/medicare-information/my-guide-to-medicare/hsa-fsa-hdhp

• Mason, D. J., Gardner, D. B., Outlaw, F. H., & O'Grady, E. T. (2016). Policy & politics in nursing and health care. St. Louis, MO: Elsevier.

• Pedulla, D. M. (n.d.). Medicare: Finding your way through the maze. PsycEXTRA Dataset. doi:10.1037/e504582016-001

• Secretary, H. O. (2015). State By State. Retrieved November 01, 2016, from http://www.hhs.gov/healthcare/facts-and-features/state-by-state/index.html

“ We keep moving forward, opening new doors, and

doing things because we’re curious and curiosity keeps

leading to new paths.”Walt Disney