HI 225 Ch04 pp ts.ab202017

1. © 2018 American Health Information Management Association© 2018 American Health Information Management Association
Principles of Healthcare Reimbursement
Sixth Edition
Anne B. Casto, RHIA, CCS

2. © 2018 American Health Information Management Association
Chapter 4
Government-Sponsored Healthcare Programs
• Learning Objectives
– Identify the different government-sponsored
healthcare programs
– Recall the history of the Medicare and
Medicaid programs in the United States
– Describe the effect that government-
sponsored healthcare programs have on the
US healthcare system
2

3. © 2018 American Health Information Management Association
Medicare
• Title XVIII of the Social Security Act
– 1965 (implemented 1966)
– Beneficiaries
• Age 65 or older
– Eligible for Social Security or Railroad Retirement
Benefits
• Persons with permanent disability
• End-stage renal disease
3

4. © 2018 American Health Information Management Association
Part A
Hospitalization
Insurance
Part B
Voluntary supplemental
medical insurance
Part C
Managed care option
Combines Parts A & B
Part D
Outpatient prescription
drug coverage
Medicare
4

5. © 2018 American Health Information Management Association
Medicare Part A
• Hospitalization Insurance
– Provided with no premiums
– Cost sharing includes deductible, copayments
and coinsurance
• See table 4.1
– Services include
• Acute care inpatient
• Long-term care
• Skilled nursing facility
• Hospice
5

6. © 2018 American Health Information Management Association
Medicare Part B
• Voluntary supplemental insurance
– Requires a premium to purchase (this is why it’s
called voluntary)
– Cost sharing includes deductible, copayments
and coinsurance
• See table 4.2
– Services include:
• Physician services
• Outpatient hospital services (like ED)
• Medical supplies
6

7. © 2018 American Health Information Management Association
Medicare Part C
• Medicare Advantage
– Managed care (managed care is discussed in detail in
Chapter 5 of the textbook)
• Combines Parts A & B
• Many Part C plans also provide Part D
– Plan requires a premium and may have cost sharing
provisions depending on the plan selected by the
beneficiary
• Expanded scope of services included in Part C
including: custodial care, dental services, vision
services, health and wellness services and
hearing aids
7

8. © 2018 American Health Information Management Association
Medicare Part D
• Outpatient prescription drug benefit
– Administered by prescription drug plans and
Medicare Advantage plans
– Premium, deductible and copayments are
applicable
8

9. © 2018 American Health Information Management Association
Medigap
• Supplementary insurance to cover items
and services not covered by Medicare
– Offered by various insurance providers
– Must meet federal guidelines
9

10. © 2018 American Health Information Management Association
Medicaid
• Title XIX of Social Security Act (1965)
– Individuals and families with low incomes and limited
financial resources
– Joint program between federal government and
states
– Administered by individual states
• Determine eligibility, type, amount, durations, scope of
covered services
• May offer a managed care option
10

11. © 2018 American Health Information Management Association
Medicaid Requirements
• Must provide coverage for:
– Poverty-related infants, children and pregnant women
– Low-income families
– Families receiving transitional medical assistance
– Children with Title IV-E adoption assistance, foster care, or
guardianship care, and children aging out of foster care
– Elderly and disabled individuals receiving Social Security
incomes and aged, blind, and disabled individuals who live
in 209(b) states
– Certain working individuals with disabilities
– Certain low-income Medicare enrollees such as Specified
Low-Income Medicare Beneficiary (SLMB)
11

12. © 2018 American Health Information Management Association
Programs of All-Inclusive Care
for the Elderly
• PACE
– Joint Medicare-Medicaid venture
– Offers states the option of creating and administering
a managed care option for the frail elderly population
in the community
– Enhance the quality of life for the frail elderly
population
• Live in their own homes and communities
• Have service facilities in various geographical service areas
– Increased accessibility to frail elderly population
12

13. © 2018 American Health Information Management Association
Children’s Health Insurance
Program
• CHIP
– Title XXI of Social Security Act
• CHIP is a state–federal partnership that targets the growing number
of children not covered by health insurance
– Like Medicaid CHIP varies from state to state
– Requirements for services that must be provided
– Requirements limiting cost sharing provisions
• About 9 million children are currentlyenrolled in CHIP
13

14. © 2018 American Health Information Management Association
TRICARE
• TRICARE
– Active-duty members of the military and qualified
family members
– Activated guard or reserve members
• Comprehensive coverage
– Outpatient visits
– Hospitalization
– Preventive care
– Maternity
– Immunizations
– Mental/behavioral health
14

15. © 2018 American Health Information Management Association
TRICARE
• Options
– TRICARE Prime and Prime Remote
• ADSM or ADFM
– TRICARE Select and Select Overseas
• ADFM
– TRICARE Young Adult
• ADFM aged 21 to 25
– TRICARE Reserve and Retired Reserve
• Qualified National Guard and Reserve members
– TRICARE for Life
• Secondary coverage for those eligible for Medicare
15
ADSM = active duty service
member
ADFM = active duty family
member

16. © 2018 American Health Information Management Association
Veterans Health Administration
• VA – Nation’s largest integrated healthcare
system
– 1,700 care sites
– 8.7+ million veterans served each year
– Little or no cost to its members
• Coverage is based on Priority Groups (see figure 4.3)
– Private insurance can be used to supplement VA
benefits
• For example, private insurance to cover VA co-
payments
16

17. © 2018 American Health Information Management Association
Civilian Health and Medical
Program of the Department of
Veterans Affairs
• CHAMPVA
– Dependents and survivors of permanently and totally
disabled veterans
– Survivors of veterans who died of service-related
conditions
– Survivors of military personnel who died in the line of
duty (not due to misconduct)
• If a family member qualifies for TRICARE, then
they cannot enroll in CHAMPVA
• Enrollees are treated at participating VA
healthcare facilities
– Outpatient deductible and some cost sharing
provisions
17

18. © 2018 American Health Information Management Association
Indian Health Service
• IHS
– American Indians
– Alaska Natives
– Covers:
• Preventive health services
• Primary medical services (hospital and ambulatory
care)
• Community health services
• Rehabilitative services
18

19. © 2018 American Health Information Management Association
Workers’ Compensation
• Workers’ compensation
– Work-related injuries
– Covers:
• Healthcare costs
• Income loss
– Legislated by individual states
• Set coverage
– Burial, death, income and medical
19

20. © 2018 American Health Information Management Association
Workers’ Compensation
• Federal Employee’s Compensation Act
– Federal government employees
– Established in 1916 and administered by the
Office of Workers’ Compensation Programs
• Example: postal workers
20