Medicare overview

[deborah eaton]

Here it is with a few things added!

It was an increase of $519 BILLION in 2010 to $929 BILLION in 2020.

Wow, class was a bit depressing today.

See you all next week!

 

[Rhonda Janes]

Hey Debbie.  I can't get the document to download.  Can you email the content to me?  Thanks girlie!
Rhonda

[deborah eaton]

Deborah Eaton

NUR 212

Medicare

Who Qualifies:

·         65 and older

·         Younger than 65 with disabilities

·         End stage renal failure, dialysis patients

• Those eligible for Social Security Disability Insurance and have Lou Gehrig's disease

·         Those receiving Social Security are automatically enrolled

·         Those not receiving SS need to enroll through the SS office

Part A

Funded mostly through payroll taxes.- Federal

·         Hospital stay; at least 3 days in length

·         Skilled care nursing facility

·         Hospice care

·         Home health services

Premium

Most Medicare enrollees do not pay a monthly Part A premium.  If an individual or their spouse has paid into Medicare for 10 years they do not have a monthly premium for Part A.  If a Medicare-eligible person has not paid in to Medicare-covered employment over 10 years they may purchase Part A for a monthly premium of $450.

·         Deductibles and Copays

·         a Part A deductible of $1,132 (2011) for a hospital stay of 1-60 days

·         a $283 per day co-pay (2011) for days 61-90 of a hospital stay

·         a $566 per day co-pay (2011) for days 91-150 of a hospital stay

·         all costs for each day beyond 150 days

·         coinsurance for skilled nursing is $141.50 per day (2011) for days 21 through 100

·         3-pint blood deductible for both Part A and Part B (these separate deductibles do not overlap)

Part B

Funded through general revenues and premiums.- federal and individuals

·         physician and nursing services

·         x-rays

·         laboratory tests

·         influenza and pneumonia vaccinations

·         blood transfusions

·         Some other outpatient medical treatments administered in a doctor's office

·         Medication administration is covered under Part B only if it is administered during an office visit

·         limited ambulance transportation

·         durable medical equipment including canes, walkers, wheelchairs, and mobility scooters

·         prosthetic devices such as artificial limbs and breast prosthesis

·         one pair of eyeglasses following cataract surgery

·         oxygen for home use

Premiums

·         Base Part B premium for 2011 is $96.40 per month.

·         Individuals with incomes over $80,000 (individuals) or $160,000 (married couples) income-adjustment premiums:

o    $85,000 or below for individuals, $170,000 or below for joint returns: $115.40

o    $85,001-$107,000 individual, $170,001-$214,000 joint: $161.50

o    $107,001-$160,000 individual, $214,001-$320,000 joint: $230.70

o    $160,001-$214,000 individual, $320,001-$428,000 joint: $299.90

o    Above $214,000 individual, above $428,000 joint: $369.10

These premiums are usually automatically taken out of monthly Social Security checks.

 

Deductible

After an individual meets the yearly deductible of $145.50 (2011), they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B. They are also required to pay an excess charge of 15% for services provided by a Medicare provider who does not accept assignment.

Not Covered Under A and B

·         Dental care, dentures

·         Hearing aids

·         Eye glasses, eye exams

Part C: Medicare Advantage plans

·         Balanced Budget Act of 1997, individuals given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs are called "Medicare+Choice", "Part C", or called "Medicare Advantage" (MA) plans.

·         Medicare pays the private health plan a set amount every month for each member. Members may have to pay a monthly premium in addition to the Medicare Part B premium and generally pay a fixed amount (a copayment of $20 for example) every time they see a doctor. The copayment can be higher to see a specialist.

·         The private plans are required to offer a benefit “package” that is at least as good as Medicare’s and cover everything Medicare covers, but they do not have to cover every benefit in the same way. Plans that pay less than Medicare for some benefits, like skilled nursing, can balance their benefits package by offering lower copayments for doctor visits.

·         Private plans use some of the excess payments they receive from the government for each enrollee to offer supplemental benefits. Some plans put a limit on their members’ annual out-of-pocket spending, providing some insurance against catastrophic costs over $5,000. But many plans use the excess subsidies to offer dental coverage and other services not covered by Medicare. Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan (MAPD).

Part D: Prescription Drug plans

Funded through general revenues, individual premiums and state Medicaid payments.

·         Medicare Part D went into effect on January 1, 2006

·         Anyone with Part A or B is eligible for Part D

·         Made possible by the passage of the Medicare Prescription Drug Improvement and Modernization Act

·          Individuals must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MAPD).

·         These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies.

·         Coverage is not standardized. Plans choose which drugs they wish to cover and at what level they wish to cover them. Medicare specifically excludes from all plans coverage for benzodiazepines, cough suppressants and barbiturates, among others. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.

Medicaid will pay for drugs not covered by Part D, such as benzodiazepines, if beneficiaries are dual-eligible (meaning eligible for both Medicare and Medicaid).

Medicare Supplement (Medigap) Policies

·         These plans help fill the holes found in Original Medicare.

·         Medigap insurance policies are standardized by CMS, but are sold and administered by private companies.

·         Medigap policies sold after the introduction of Medicare Part D are prohibited from covering drugs.

 

Increasing prices of health care + increasing use of services + new technologies=increase in health care cost!

·         Individuals receiving Medicare will rise from 47 million in 2010 to 80 million in 2030.

·         Spending will increase:  $519 billion in 2010 to $929 billion in 2020

·         Part A fund could be depleted by 2029!