Term Paper: Disaster Recovery PlanDue Week 10 and worth 200 pointsThis assignment consists of two (2) parts: a written paper and a PowerPoint presentation. You must submit both parts as separate files

AARP. (2017). Medicare, Medicaid and ACA. Retrieved from https://www.aarp.org/ppi/issues/medicare/

Beckers Healthcare. (2013, February 8). 18 recent Medicare, Medicaid issues. Retrieved from https://www.beckershospitalreview.com/finance/18-recent-medicare-medicaid-issues-feb-8-2013.html

Center on Budget and Policy Priorities. (n.d.). Policy basics: Introduction to Medicaid. Retrieved from https://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid

U.S. Department of Health and Human Services. (2016). What is the difference between Medicare and Medicaid? Retrieved from https://www.hhs.gov/answers/medicare-and-medicaid/what-is-the-difference-between-medicare-medicaid/index.html

Kaiser Health News. (2015, July 30). 5 challenges facing Medicaid at 50. Retrieved from the U.S. News & World Report website at https://www.usnews.com/news/articles/2015/07/30/5-challenges-facing-medicaid-at-50

Rajaram, R., & Bilimoria, K. (2015). Medicare. JAMA, 314(4), 420.

MedPAC. (2017). Report to the Congress: Medicare and the Health Care Delivery System. Retrieved from http://www.medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf

Videos

NAAIP. (2016, April 27). Medicare explained in two minutes [Video file]. Retrieved from https://www.youtube.com/watch?v=i9wGIaKE6fA

NAAIP. (2015, December 13). What is Medicaid? Excellent explanation by a board-certified elder care attorney [Video file]. Retrieved from https://www.youtube.com/watch?v=O3uY8ycWbrQ

Hofstrand, D. (2016). Vision and mission statements—A roadmap of where you want to go and how to get there. Retrieved from https://www.extension.iastate.edu/agdm/wholefarm/pdf/c5-09.pdf

Josiah Macy Jr. Foundation. (2008). Continuing education in the health professions: Improving healthcare through lifelong learning. Retrieved from http://macyfoundation.org/docs/macy_pubs/Macy_ContEd_1_7_08.pdf

OSHA. (n.d.). Education and Training. Retrieved from https://www.osha.gov/dsg/hospitals/education_training.html

Module 4 - Home

Medicare, Medicaid, and the Delivery System

Modular Learning Outcomes

Upon successful completion of this module, the student will be able to satisfy the following outcomes:

• Case

  • Analyze Medicaid and Medicare issues/challenges and discuss the impact on health care delivery.

• SLP

  • Examine an executive summary of recommendations to Congress on health care delivery and hypothesize recommendation potential outcomes.

• Discussion

  • Discuss and assess the difference between Medicare Advantage, Qualified Health Plans, and Medicaid Managed Care Organizations.

Module Overview

What Is Medicare?

Medicare is health insurance for the following:

• People age 65 or older.

• People younger than 65 with certain disabilities.

• People of any age with End-Stage Renal Disease (ESRD)—permanent kidney failure requiring dialysis or a kidney transplant.

The Different Parts of Medicare

Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, and hospice, as well as home health care.

Part B helps cover medically necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services.

Part C is a Medicare managed care plan. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.

Part D is Medicare prescription drug coverage, which is an insurance run by an insurance company or other private company approved by Medicare. To join a Medicare Prescription Drug Plan, beneficiaries must have Medicare Part A or Part B.

What Is a Medicare Advantage Plan (Part C)?

A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care). These rules can change each year.

Different Types of Medicare Advantage Plans

• Health Maintenance Organization (HMO) Plans

• Preferred Provider Organization (PPO) Plans

• Private Fee-for-Service (PFFS) Plans

• HMO Point of Service (HMOPOS) Plans—HMO plans that may allow beneficiaries to get some services out of network for a higher cost.

• Medical Savings Account (MSA) Plans—Plans that combine a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). Beneficiaries can use the money to pay for health care services during the year.

• Medicaid

Until 2014, when the Affordable Care Act expanded Medicaid eligibility, Medicaid did not provide medical assistance for all poor persons. Under the broadest provisions of the federal statute, Medicaid does not currently provide health care services even for very poor persons unless they are in one of the groups designated below. Low income is only one test for Medicaid eligibility for those within these groups; their financial resources also are tested against threshold levels (as determined by each state within federal guidelines).

States generally have broad discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. To be eligible for federal funds, however, states are required to provide Medicaid coverage for certain individuals who receive federally assisted income-maintenance payments, as well as for related groups not receiving cash payments. In addition to their Medicaid programs, most states have additional “state-only” programs to provide medical assistance for specified poor persons who do not qualify for Medicaid. Federal funds are not provided for state-only programs. The following enumerates the mandatory Medicaid “categorically needy” eligibility groups for which federal matching funds are provided:

Limited-income families with children, as described in section 1931 of the Social Security Act, are generally eligible for Medicaid if they meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996.

• Children under age 6 whose family income is at or below 133 percent of the FPL. (As of January 2010, the FPL has been set at $22,050 for a family of four in the continental U.S.; Alaska and Hawaii’s FPLs are substantially higher.)

• Pregnant women whose family income is below 133 percent of the FPL. (Services to these women are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care.)

• Infants born to Medicaid-eligible women, for the first year of life with certain restrictions.

• Supplemental Security Income (SSI) recipients in most states (or aged, blind, and disabled individuals in states using more restrictive Medicaid eligibility requirements that pre-date SSI).

• Recipients of adoption or foster care assistance under Title IV-E of the Social Security Act.

• Special protected groups (typically individuals who lose their cash assistance under Title IV-A or SSI due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time).

• All children under age 19 in families with incomes at or below the FPL.

• Certain Medicare beneficiaries (e.g., certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage, but below the FPL).

Payment of Medicaid Services

Medicaid operates as a vendor payment program. States may pay health care providers directly on a fee-for-service basis, or states may pay for Medicaid services through various prepayment arrangements, such as through Health Maintenance Organizations (HMOs). Within federally imposed upper limits and specific restrictions, each state for the most part has broad discretion in determining the payment methodology and payment rate for services. Generally, payment rates must be sufficient to enlist enough providers so that covered services are available at least to the extent that comparable care and services are available to the general population within that geographic area. Providers participating in Medicaid must accept Medicaid payment rates as payment in full. States must make additional payments to qualified hospitals that provide inpatient services to a disproportionate number of Medicaid beneficiaries and/or to other low-income or uninsured persons under what is known as the “disproportionate share hospital” (DSH) adjustment.

States may impose nominal deductibles, coinsurance, or co-payments on some Medicaid beneficiaries for certain services. The following Medicaid beneficiaries, however, must be excluded from cost sharing: pregnant women, children under age 18, and hospital or nursing home patients who are expected to contribute most of their income to institutional care. In addition, all Medicaid beneficiaries must be exempt from co-payments for emergency services and family planning services.

A significant development in Medicaid is the growth in managed care as an alternative service delivery concept different from the traditional fee-for-service system. Under managed care systems, HMOs, prepaid health plans (PHPs), or comparable entities agree to provide a specific set of services to Medicaid enrollees, usually in return for a predetermined periodic payment per enrollee. Managed care programs seek to enhance access to quality care in a cost-effective manner. Waivers may provide the states with greater flexibility in the design and implementation of their Medicaid managed care programs. The number of Medicaid beneficiaries enrolled in some form of managed care program is growing rapidly, from 48 percent of enrollees in 1997 to 71.7 percent in 2009.

Centers for Medicaid and Medicare. (2017). Medicare. Retrieved from https://www.cms.gov/Medicare/Medicare.html

Centers for Medicaid and Medicare. (2017). Medicaid. Retrieved from https://www.medicaid.gov/medicaid/index.html

Model of Medicaid Managed Care

• State-managed care agencies contract for health care services through a variety of managed care arrangements. The major Medicaid managed care models are:Risk-Based Managed Care Organization (MCO): Under the risk-based model, a MCO is paid a fixed monthly fee per enrollee and assumes part or all of the financial risk for the delivery of health care services. Some MCO plans may only contract on a limited basis (e.g., mental health or primary care services only).

• Primary Care Case Management (PCCM): Under the PCCM model, a primary care clinician (generally a PCP) is responsible for coordinating and monitoring the provision of services to the Medicaid beneficiaries. These primary care clinicians do not assume the financial risk for the provision of care and are paid a small fee per person per month to provide basic care and coordinate specialist care. Other needed services are usually paid fee-for-service.