This document summarizes key aspects of the US health care system. It outlines the main parts of Medicare including Part A for hospital coverage, Part B for medical coverage, Part C for Medicare Advantage plans, and Part D for prescription drug coverage. It also describes Medicaid coverage for low-income groups. The document discusses different reimbursement methods like fee-for-service and bundled payments. It provides an overview of provisions of the Affordable Care Act related to coverage, costs, and care. The influence of policy on reimbursement and value-based programs is examined. Access issues for uninsured patients and the need for federal funding or Medicaid expansion are noted.

1. US Health Care
NICOLE ANDERSON
11/7/2016
MSN 603
DR TARRANT

2. Medicare
• Part A-Hospital
• Inpatient hospitalizations, Home health, Hospice, Skilled nursing facilities (not custodial or
long-term care)
• Some may not pay a premium, if they have payroll deductions
• Part B- Medical
• Physician appointments and outpatient hospital services
• May cover some services not covered by Part A
• I.E. physical and occupational therapist
• Many pay a monthly premium
• Part C
• Medicare Advantage program
• Part D
• Prescription drugs not covered under part A and B
• Many pay a monthly premium

3. Medicaid
• coverage for
• pregnant women,
• children under age 6
• families at or below the poverty level
• States must provide minimum set of benefits
• Required to pay Medicare premiums
• Deductibles and copayments

4. Reimbursement
• Fee-for-service
• Charge provided for each service
• Submit claims to insurers for payment
• Physician/Clinician reimbursement (Under fee-for-
service)
• Codes are picked based on IDC-10 and then payment
levels are assigned
• Prospective payment systems (PPS)
• Payment established based on diagnosis-related groups
• Bundled payments/Global payments
• Providers paid a flat rate for an episode of care
• Insurer is paid per member per month

5. Affordable Care Act
ACA

6. ACA-
Coverage
• Ends pre-existing conditions exclusion
for children
• Young adults coverage
• Ends arbitrary withdrawals of
insurances
• Right to appeal
Cost
• Ends lifetime limits on coverage
• Reviews premium increases
• Companies must justify any rate increase
• Getting more from your premium
dollars

7. ACA- continued
Care
• Covers preventive care
• Patients choice of doctors
• Ability to choose primary doctor
patients wants
• Removes barriers to emergency services
• Ability to seek ER care at hospital
outside your network

8. Policy Influences
• The influence of policy on this process and what that means to the
patients financial obligations.
• The Accountable Care Act (ACA) emphasizes higher quality care for
low payments.
• No reimbursement for hospital-acquired conditions and VBP
• 30 readmissions for key diagnoses, HAC”s, lack of meaningful use

9. Patients with no insurance
• Clinics treating these patients need to apply for federal funding such as
grants and donations
• Patients need to have access to Medicare/Medicaid
• It is not feasible for a clinic to stay open finically without these options

10. References
• @. (n.d.). Healthcare Costs: What Are HSAs, FSAs, HRAs, and HDHPs?
Retrieved November 01, 2016, from
http://www.healthline.com/health/medicare-information/my-guide-to-
medicare/hsa-fsa-hdhp
• Mason, D. J., Gardner, D. B., Outlaw, F. H., & O'Grady, E. T. (2016). Policy
& politics in nursing and health care. St. Louis, MO: Elsevier.
• Pedulla, D. M. (n.d.). Medicare: Finding your way through the maze.
PsycEXTRA Dataset. doi:10.1037/e504582016-001
• Secretary, H. O. (2015). State By State. Retrieved November 01, 2016, from
http://www.hhs.gov/healthcare/facts-and-features/state-by-
state/index.html

11. “ We keep moving forward,
opening new doors, and doing
things because we’re curious and
curiosity keeps leading to new
paths.”
Walt Disney