The document provides an overview of the United States healthcare system, which includes both public and private initiatives. It describes the two primary public programs, Medicare and Medicaid. Medicare provides health insurance for those aged 65 and older, while Medicaid is for low-income individuals. The document also provides guidance on selecting insurance based on residency status, employment, health needs, and family size. It outlines how to apply for insurance through employers, open markets, or state/local programs. Tips are provided on obtaining coverage and understanding benefits and responsibilities.

1. Welcome to the United States
HealthCare System
Starter Kit For New Residents
Author Tammy Burke RN

2. What is the make-up of the United States
HealthCare System?
 A complex mix of public and private initiatives
 Healthcare is primarily paid for using private insurance in a free market system
 Third party such as employers and public insurers pay the bulk of health care costs.
 Two primary federal social health programs
 Medicare
 Medicaid

3. Medicare
 Created under title XVIII of the 1965 social security act as health insurance for aged
and disabled.
 For individuals 65 years and older
 Four parts A, B. C, D
 Part A hospital insurance
 Part B medical insurance
 Part C expands beneficiaries’ options for participation in private sector health care plans.
 Part D helps pay for prescriptions otherwise not covered by A and B.

4. Medicaid
 Passed by congress in 1965 as a response to perceived inadequacy of welfare
medical care.
 Financed by Federal and State funding.
 Originally only covered pregnant women and children under the age of 6 from families at or
below 133% of federal poverty level.
 Currently open to individuals less than 65years at or below a poverty level of 138%.

5. Your guide to selecting insurance
 Residency status
 US resident?
 Employment status
 Have a job?
 Health needs
 Care models
 Health Maintenance Organization (HMO)
 Physician lead care
 Physician required referrals to specialists
 Managed Care System
 Low cost
 Perferred Provider Organization (PPO)
 Open-ended access to providers
 No Referrals to specialists
 Slightly higher costs
 Family size
 Location

6. How to apply for health insurance
 Employer
 Required by law to provide health insurance
 Open Market at healthcare.gov
 Self purchased health insurance
 Nevada Department of Health and Human Services
 Provide information for state and federal health programs (dhhs.nv.gov)
 Nevada Local Programs
 Community Health Alliance
 Disability Rx
 Senior Rx
 Nevada Primary Care Association

7. Health Insurance Tips
 Obtain coverage
 Find out when your coverage starts, DON’T FALL INTO THE GAP!
 Know when your coverage begins and important dates.
 Know your benefit
 What is covered?
 Know your responsibilities
 What do you have to pay for?
 Know how to access care
 Where should you go for care?
 Be prepared for any potential health crisis
 Have savings available for emergencies
 Know your support systems
 Family or friends for support

8. Care Algorithm
YES YES
NO
NO
Private INS Medicare
Medicaid
Critically
ill?
Visit your nearest
emergency room.
Have you been
admitted?
Hospital and
independently contracted
physicians are paid by
DRGs and Fee For Service
or Bundle payments.
What do you pay?
For Medicare patients
$1,288 deductible
/benefit period.
Days 1–60: $0 /benefit
period.
Days 61–90: $322
coinsurance per
day/benefit period.
Days 91 and beyond:
$644 coinsurance per
each "lifetime reserve
day" after day 90/benefit
period (up to 60 days
over your lifetime).
Beyond lifetime reserve
days: all costs.
No specific copay
listed. Prior
authorization may be
required for
nonemergent
admissions
Specific copay will be
outlined in plan of
employer sponsored
or self-purchased
health insurance.
Additional payment
may be required for
services not covered
by plan.
Follow up with
primary care
physician. See
health plan details
for copay or
coverage
Go to Urgent care or
primary care physician.
See plan details for
coverage

9. References
 Healthcare.gov. (n.d.). How can we help you? Retrieved from
https://www.healthcare.gov/get-answers/
 Kaiser Family Foundation. (2016). Medicaid Benefits: Inpatient Hospital Services, other
than in an Institution for Mental Diseases. Retrieved from http://kff.org/medicaid/state-
indicator/inpatient-hospital-services-other-than-in-an-institution-for-mental-
diseases/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sor
t%22:%22asc%22%7D
 Mason, D.J., Gardner, D.B., Outlaw, F. H., & O’Grady, E. T. (2016) Policy and politics in
nursing and healthcare (7th Edition) St Louis, MO: Elsevier
 Medicare. (2016). Your Medicare Coverage. Retrieved from
https://www.medicare.gov/coverage/hospital-care-inpatient.html
 State of Nevada Department of Health and Human Services. (2014). Medical Assistance.
Retrieved from http://dhhs.nv.gov/Find_Assistance/Medical_Assistance