Post on 13-Feb-2017
transcript
US Health CareNICOLE ANDERSON
11/7/2016MSN 603
DR TARRANT
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
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
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
Affordable Care ActACA
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
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
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
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
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
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