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- IN THIS LESSON WE WILL BE COVERING CHAPTER 4
IN YOUR REIMBURSEMENT TEXTBOOK.
CHAPTER 4 IS GOVERNMENT- SPONSORED HEALTHCARE PROGRAMS.
SOME OF THE PROGRAMS YOU WILL MORE THAN LIKELY HAVE HEARD OF,
AND SOME OF THESE WILL PROBABLY BE NEW TO YOU.
THE OBJECTIVES IN TODAY'S LECTURE INCLUDE
UNDERSTANDING THE DIFFERENCES AMONG AND IDENTIFYING
THE VARIOUS GOVERNMENT-SPONSORED HEALTHCARE PROGRAMS
THAT ARE IN THE U.S.,
THE HISTORY OF MEDICARE AND MEDICAID IN AMERICA,
AND UNDERSTANDING THE IMPACT
THAT GOVERNMENT-SPONSORED HEALTH PROGRAMS
HAVE ON OUR HEALTHCARE SYSTEM.
THE SOCIAL SECURITY ACT WAS AMENDED IN 1965
IN ORDER TO CREATE THE MEDICARE PROGRAM.
MOST OF YOU PROBABLY KNOW WHAT MEDICARE IS
OR KNOW SOMEBODY THAT'S ON MEDICARE.
MEDICARE IS BASICALLY A NATIONWIDE HEALTH INSURANCE
THAT PROVIDES HEALTH SERVICES TO THE ELDERLY
AND TO OTHER QUALIFYING PERSONS.
MEDICARE BENEFITS ARE ALSO AVAILABLE FOR THOSE PEOPLE
THAT ARE ENTITLED TO SOCIAL SECURITY
OR RAILROAD RETIREMENT DISABILITY BENEFITS
FOR AT LEAST 24 MONTHS,
GOVERNMENT EMPLOYEES WITH MEDICARE COVERAGE
WHO HAVE BEEN DISABLED FOR MORE THAN 29 MONTHS,
INSURED WORKERS AND THEIR SPOUSES
WITH END-STATE RENAL DISEASE,
AND ALSO CHILDREN WITH END-STAGE RENAL DISEASE
CAN BE COVERED UNDER MEDICARE.
IN 2010 TWO MAJOR LAWS PASSED
THAT REALLY HAD A BIG IMPACT ON THE MEDICARE SYSTEM.
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
WAS ENACTED ON MARCH 23, 2010,
AND THE HEALTHCARE EDUCATION RECONCILIATION ACT OF 2010
WAS PASSED ON MARCH 30, 2010.
SO TOGETHER THOSE TWO LAWS COMBINED ARE KNOWN AS THE ACA,
WHICH WE TALKED ABOUT LAST CHAPTER A LITTLE BIT,
OR THE AFFORDABLE CARE ACT OF 2012.
THIS BASICALLY OUTLINES SOME PROVISIONS
THAT ARE RELATED TO MEDICARE,
AND SEVERAL OF THOSE WILL BE DISCUSSED
THROUGHOUT THE TEXTBOOK,
AND IN THIS CHAPTER WE'LL LOOK AT SOME OF THAT AS WELL.
MEDICARE PART A IS BASICALLY OUR HOSPITAL INSURANCE.
IT COVERS INPATIENT HOSPITAL STAYS.
IT IS PROVIDED WITH NO PREMIUMS TO MOST BENEFICIARIES.
MOST SERVICES ARE COVERED UNDER THIS BENEFIT.
THEY DO HAVE A YEARLY DEDUCTIBLE AND COPAYMENT
THAT MUST BE PAID BY THE BENEFICIARY.
SERVICES THAT WOULD BE INCLUDED IN PART A INCLUDE, AS I SAID,
INPATIENT STAYS, YOUR LONG-TERM CARE HOSPITALIZATIONS,
SKILLED NURSING SERVICES, HOME HEALTH, AND HOSPICE.
TABLE 4.1 IN CHAPTER 4 OF YOUR TEXTBOOK
DOES OUTLINE SOME PART A SERVICES,
AND THEY CITE THE BENEFIT PERIODS,
WHAT THE PATIENT IS RESPONSIBLE FOR,
SO YOU CAN REVIEW THOSE TO KIND OF GET A BROADER IDEA.
MEDICARE PART B INSURANCE IS A SUPPLEMENTARY INSURANCE.
IT IS OPTIONAL
THAT BENEFICIARIES CAN PURCHASE IF THEY CHOOSE TO.
IN 2012 THE PREMIUM PER MONTH WAS $99.90.
BASICALLY PART B WOULD COVER PHYSICIAN SERVICES,
MEDICAL SERVICES, AND MEDICAL SUPPLIES,
OR BASICALLY THE BULK OF WHAT IS NOT COVERED UNDER PART A.
MOST OF THESE THINGS ARE PROVIDED ON AN OUTPATIENT
OR AMBULATORY BASIS.
IN ADDITION TO THAT MONTHLY PREMIUM,
PATIENTS ARE RESPONSIBLE FOR A DEDUCTIBLE AND FOR COPAYMENTS.
THERE IS ALSO A TABLE IN YOUR BOOK, TABLE 4.2,
THAT OUTLINES PART B SERVICES.
BECAUSE SOME ITEMS ARE EXCLUDED FROM PART A OR PART B COVERAGE,
BENEFICIARIES CAN GO AHEAD AND PURCHASE ADDITIONAL COVERAGE,
OR CHOOSE MEDICARE PART C, ALSO KNOWN AS MEDICARE ADVANTAGE,
IF THEY CHOOSE THE MEDICARE MANAGED CARE OPTION
IN ORDER TO GET INSURANCE.
WHAT'S COVERED UNDER PART C THAT ARE NOT COVERED IN A OR B
WOULD BE LONG-TERM NURSING HOME CARE,
CUSTODIAL CARE, DENTAL, VISION, ROUTINE EXAMS, WELLNESS,
ACUPUNCTURE, HEARING AIDS, THOSE TYPE OF THINGS.
MEDICARE PART D IS WHAT WE CALL OUR DRUG BENEFIT,
AND IT WAS CREATED IN 2003, BUT FULLY IMPLEMENTED IN 2006.
WHAT THIS PROGRAM DOES IS OFFER OUTPATIENT DRUG COVERAGE
PROVIDED BY PRIVATE PRESCRIPTION DRUG PLANS
AND MEDICARE ADVANTAGE.
BENEFICIARIES PAY A MONTHLY PREMIUM THAT VARIES,
BUT IT CAN BE AS LOW AS $15 A MONTH.
IN ADDITION TO THAT,
BENEFICIARIES ALSO HAVE A DEDUCTIBLE
THAT THEY HAVE TO MEET EACH YEAR
AND COPAYMENTS WITH THEIR PRESCRIPTION.
MEDIGAP IS A SUPPLEMENTARY INSURANCE AS WELL,
AND IT COVERS MOST COST SHARING EXPENSES,
AS SHOWN IN THOSE TWO TABLES THAT I JUST TALKED ABOUT.
THOSE POLICIES, THEY HAVE TO MEET FEDERAL STANDARDS
OFFERED BY THE DIFFERENT INSURANCE COMPANIES,
THE PRIVATE POLICIES THAT PATIENTS CAN PICK UP.
ORIGINALLY KNOWN AS THE MEDICAL ASSISTANCE PROGRAM,
MEDICAID WAS ADDED TO THE SOCIAL SECURITY ACT IN 1965.
IT IS A JOINT PROGRAM
BETWEEN THE FEDERAL AND THE STATE GOVERNMENTS
TO PROVIDE HEALTHCARE BENEFITS TO LOW-INCOME PERSONS
AND THEIR FAMILIES.
SO BASICALLY THE KEY TO REMEMBER IS IT'S A JOINT PROGRAM.
IT'S NOT COMPLETELY RUN BY THE GOVERNMENT.
IT IS NOT COMPLETELY RUN BY THE STATE.
IT IS ADMINISTERED BY EACH INDIVIDUAL STATE,
SO EACH INDIVIDUAL STATE CAN DEVELOP AND MAINTAIN
THE UNIQUE PROGRAM TO THEIR STATE.
THEY WILL EACH DETERMINE
WHAT ARE THE ELIGIBILITY REQUIREMENTS,
WHAT SERVICES WILL BE COVERED,
AND FOR THAT REASON COVERAGE FROM STATE TO STATE
IS VERY, VERY DIFFERENT.
A PERSON THAT QUALIFIES IN ONE STATE
MAY NOT BE COVERED IN ANOTHER STATE.
FOR A STATE TO QUALIFY TO RECEIVE
THESE MEDICAID FEDERAL FUNDS,
THE STATE'S PROGRAM HAS TO PROVIDE COVERAGE
FOR AT LEAST THESE GROUPS HERE,
THE LOW-INCOME FAMILIES WITH CHILDREN,
SUPPLEMENTARY SECURITY INCOME RECIPIENTS,
INFANTS BORN TO MEDICAID ELIGIBLE MOMS,
CHILDREN YOUNGER THAN SIX
WHOSE FAMILY INCOME IS AT OR BELOW 133%
OF THE FEDERAL POVERTY LEVEL,
RECIPIENTS OF ADOPTION ASSISTANCE AND FOSTER CARE,
CERTAIN MEDICARE BENEFICIARIES, AND SPECIAL PROTECTED GROUPS.
THE PERSONAL RESPONSIBILITY
AND WORK OPPORTUNITY RECONCILIATION ACT OF 1996,
ALSO KNOWN AS WELFARE REFORM,
BROUGHT A LOT OF CHANGES TO MEDICAID.
SO FOR EXAMPLE, WELFARE REFORM REPEALED AID TO FAMILIES
WITH DEPENDENT CHILDREN PROGRAM,
AND IT WAS REPLACED WITH THE TANF PROGRAM.
BASICALLY THIS PROVIDES STATES WITH GRANT MONEY
THAT'S DESIGNATED TO PROVIDE LOW-INCOME FAMILIES
WITH CASE ASSISTANCE.
THE PACE PROGRAM IS A JOINT MEDICARE/MEDICAID VENTURE
THAT OFFERS STATES THE OPTION OF CREATING AND ADMINISTERING
CAPITATED MANAGED CARE OPTIONS FOR THE ELDERLY POPULATION.
PACE WAS BASICALLY DESIGNED TO ENHANCE THE QUALITY OF LIFE
FOR THOSE FRAIL ELDERLY,
THAT ALLOWS THEM REALLY TO LIVE IN THEIR OWN HOMES
AND COMMUNITIES,
AND TRY TO PRESERVE AND SUPPORT THE FAMILY UNIT.
BENEFICIARIES OF THE PACE PROGRAM, AS WE TALKED ABOUT,
THEY'RE FRAIL, ELDERLY PERSONS,
BUT THEY HAVE TO MEET CERTAIN REQUIREMENTS AS WELL.
THEY HAVE TO BE AT LEAST AGE 55 OR OLDER.
THEY MUST BE A RESIDENT IN A DESIGNATED PACE SERVICE AREA.
THEY HAVE TO BE ASSESSED BY A PACE TEAM,
AND THEY HAVE TO BE CERTIFIED BY THE STATE AGENCY
AS ELIGIBLE FOR NURSING HOME LEVEL OF CARE.
SO THEY HAVE TO BE FRAIL ENOUGH TO BE ON THAT LEVEL OF CARE.
CHIP WAS CREATED IN '97 BY THE BALANCED BUDGET ACT.
IT WAS RENEWED AND STRENGTHENED
THROUGH THE CHILDREN'S HEALTH INSURANCE PROGRAM
REAUTHORIZATION ACT OF 2009.
BASICALLY CHIP IS A STATE-FEDERAL PARTNERSHIP
THAT TARGETS A GROWING NUMBER OF CHILDREN
THAT ARE NOT COVERED BY PRIVATE HEALTH INSURANCE.
SINCE IT WAS CREATED, CHIP HAS PROVIDED SERVICES
FOR MORE THAN 40 MILLION CHILDREN,
SO A VERY, VERY IMPORTANT PROGRAM.
IT'S DESIGNED TO PROVIDE INSURANCE
FOR CHILDREN OF FAMILIES WHOSE INCOME IS TOO HIGH
TO QUALIFY FOR MEDICAID,
BUT IT'S TOO LOW TO BE ABLE TO AFFORD THE PREMIUMS AND COSTS
ASSOCIATED WITH PRIVATE HEALTH PLANS.
LIKE MEDICAID, CHIP VARIES FROM STATE TO STATE.
EACH STATE HAS TO DETERMINE
HOW IT'S GOING TO DELIVER THE BENEFITS
AND ALL THOSE PIECES THAT COME INTO PLAY THERE.
STATES HAVE TO PROVIDE THE FOLLOWING SERVICES
TO CHIP BENEFICIARIES:
INPATIENT HOSPITAL STAYS, OUTPATIENT HOSPITAL SERVICES,
PHYSICIANS, MEDICAL AND SURGICAL SERVICES, LAB AND X-RAY,
WELL BABY CHILDCARE, INCLUDING IMMUNIZATIONS, AND DENTAL.
THE DEPARTMENT OF DEFENSE PROVIDES HEALTHCARE PROGRAMS
FOR ACTIVE-DUTY AND RETIRED MEMBERS OF THE SEVEN SERVICES
OF THE UNITED STATES.
THOSE ARE AIR FORCE, ARMY, COAST GUARD, MARINE, NAVY,
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION
COMMISSIONED CORPS,
AND PUBLIC HEALTH SERVICES.
SO COVERAGE IS ALSO PROVIDED FOR FAMILIES AND THEIR SURVIVORS.
THE PROGRAM IS NOW CALLED TRICARE.
IT DID USED TO BE CALLED CHAMPUS,
SO THINGS CHANGED IN 1966
WITH AMENDMENTS TO THE DEPENDENTS MEDICAL CARE ACT.
MEDICARE PROVIDES COMPREHENSIVE COVERAGE FOR ALL BENEFICIARIES.
IT INCLUDES OUTPATIENT VISITS, HOSPITALIZATION,
PREVENTATIVE SERVICES, MATERNITY CARE, IMMUNIZATION,
AND MENTAL HEALTH SERVICES.
ALL ACTIVE-DUTY SERVICE MEMBERS ARE COVERED
UNDER ONE OF THESE TRICARE OPTIONS.
TRICARE REMOTE OR PRIME REMOTE IS REQUIRED
WHEN THE SERVICE MEMBERS LIVE AND WORK IN REMOTE AREAS.
SO IN THIS OPTION THE MEMBERS MAY HAVE ACCESS TO PRIMARY CARE
FROM OUT OF NETWORK,
AND THE PROVIDERS ARE UNAVAILABLE IN THEIR AREA
THAT ARE IN NETWORK.
THERE ARE NO ENROLLMENT FEES, DEDUCTIBLES OR COPAYMENTS
FOR SERVICES AND PRESCRIPTION
WITH TRICARE PRIME OR PRIME REMOTE.
THE TRICARE STANDARD AND STANDARD OVERSEAS,
THIS IS BASICALLY THE SAME CONCEPT
AS PRIME AND PRIME REMOTE,
BUT THESE ACTIVE-DUTY OR FAMILY MEMBERS ARE LOCATED OVERSEAS.
THE TRICARE YOUNG ADULT, THIS IS THE PLAN ACTION
AVAILABLE TO YOUNG ADULT CHILDREN
OF ACTIVE-DUTY SERVICE MEMBERS, RESERVE MEMBERS,
AND MILITARY RETIREES.
SOMEONE WOULD QUALIFY IF THEY ARE A CHILD
OF ONE OF THOSE PERSONS JUST MENTIONED,
THEY ARE BETWEEN 21 AND 25 YEARS OLD, THEY ARE UNMARRIED,
AND THEY'RE NOT ELIGIBLE TO ENROLL
IN AN EMPLOYER-SPONSORED HEALTH PLAN
TIED TO THEIR OWN EMPLOYMENT.
THE TRICARE RESERVE AND RETIRED RESERVE,
BASICALLY IS A PREMIUM BASED HEALTH PLAN
THAT QUALIFIED NATIONAL GUARD
AND RESERVE MEMBERS CAN PURCHASE.
THERE ARE INDIVIDUAL PLANS OR A FAMILY PLAN.
THEY PAY A MONTHLY PREMIUM.
THERE IS A 15% COINSURANCE FOR OUTPATIENT
AND 20% COINSURANCE FOR OUT OF NETWORK PROVIDERS.
THE RETIRED RESERVE PLAN IS BASICALLY THE SAME,
EXCEPT THERE'S HIGHER PREMIUMS, HIGHER COINSURANCE,
AND COPAYMENT AMOUNTS.
TRICARE FOR LIFE IS AVAILABLE AS A SECONDARY INSURANCE,
SECONDARY TO MEDICARE.
MEMBERS ARE REQUIRED TO PARTICIPATE IN MEDICARE PART B
AND PAY THOSE PART B PREMIUMS.
BASICALLY THE TRICARE FOR LIFE IS GOING TO HELP LOWER
THE OUT OF POCKET EXPENSES THAT THE BENEFICIARY PAYS.
THE DEPARTMENT OF VETERANS AFFAIRS
PROVIDES COVERED HEALTHCARE SERVICES AND SUPPLIES
TO THEIR ELIGIBLE BENEFICIARIES
THROUGH THE CIVILIAN HEALTH AND MEDICAL PROGRAM
OF THE DEPARTMENT OF VETERANS AFFAIRS,
OR WHAT WE CAN CALL CHAMPVA.
THIS PROGRAM IS AVAILABLE FOR A SPOUSE OR A WIDOW
AND FOR THE CHILDREN OF VETERAN WHO MEETS CERTAIN CRITERIA.
THAT INCLUDES THEY ARE PERMANENTLY OR TOTALLY DISABLED
DUE TO A SERVICE-RELATED DISABILITY,
THEY WERE PERMANENTLY AND TOTALLY DISABLED
DUE TO A SERVICE-CONNECTED CONDITION
AT THE TIME OF THEIR DEATH,
THEY DIED IN A SERVICE-CONNECTED DISABILITY,
AND/OR DIED ON ACTIVE DUTY.
PERSONS THAT ARE ON TRICARE
CANNOT ALSO PARTICIPATE IN CHAMPVA.
THIS PROGRAM COVERS MOST HEALTHCARE SERVICES AND SUPPLIES
THAT ARE MEDICALLY NECESSARY.
CHAMPVA WOULD BECOME A SECONDARY PAYER
WHEN ANY OTHER HEALTH BENEFIT IS AVAILABLE.
THE INDIAN HEALTH SERVICE WAS CREATED
IN ORDER TO UPHOLD THE FEDERAL GOVERNMENT'S OBLIGATION
TO PROMOTE HEALTHY INDIANS, AMERICAN INDIANS
OR ALASKA NATIVE PEOPLE, THEIR COMMUNITIES AND THE CULTURE.
THE GOVERNMENT-TO-GOVERNMENT RELATIONSHIP BETWEEN THE U.S.
AND THE AMERICAN INDIAN TRIBES WAS ESTABLISHED IN 1787.
SOME OF THE COVERED SERVICES ARE PREVENTATIVE,
PRIMARY MEDICAL SERVICES OR HOSPITAL OR CLINIC ITEMS,
COMMUNITY HEALTH, SUBSTANCE ABUSE, AND ALSO REHAB.
WORKERS' COMP IS A BENEFIT
THAT'S PROVIDED TO MOST EMPLOYEES
TO COVER HEALTHCARE COSTS AND LOST INCOME
THAT RESULTS FROM A WORK-RELATED INJURY OR ILLNESS.
SO IT COVERS BOTH THE COSTS OF THE MEDICAL CARE
AS A RESULT OF THE INJURY, AND ALSO THE LOST INCOME.
IT IS MONITORED AND LEGISLATED BY THE STATES
THAT SET THE COVERAGE.
THEY ALSO SET THE EXCLUSIONS IN SPECIFIC WORKERS.
THE FEDERAL EMPLOYEE'S COMPENSATION ACT OF 1916
WAS ESTABLISHED TO BASICALLY INSURE
THAT CIVILIAN EMPLOYEES OF THE FEDERAL GOVERNMENT
ARE PROVIDED MEDICAL, DEATH, INCOME BENEFITS
FOR WORK-RELATED ACCIDENTS, ILLNESSES OR DEATH.
SO IT PROVIDES FOR MEDICAL, DEATH BENEFITS, AND FOR--