Class # 9 "Medicare, Medicaid and Tricare"
In the United States, Medicare is a single-payer, national social insurance program administered by the US federal government since 1966, currently using about 30–50 private insurance companies across the United States under contract for administration. United States Medicare is funded by a payroll tax, premiums and surtaxes from beneficiaries, and general revenue. It provides health insurance for Americans aged 65 and older who have worked and paid into the system through the payroll tax. It also provides health insurance to younger people with some disabilities status as determined by the Social Security Administration, as well as people with end stage renal disease and amyotrophic lateral sclerosis.
In 2015, Medicare provided health insurance for over 55 million—46 million people age 65 and older and nine million younger people. On average, Medicare covers about half of the health care charges for those enrolled. The enrollees must then cover their remaining costs either with supplemental insurance, separate insurance, or out-of-pocket. Out-of-pocket costs can vary depending on the amount of health care a Medicare enrollee needs. They might include the costs of uncovered services—such as for long-term, dental, hearing, and vision care—and supplemental insurance premiums.
Medicare Part A covers hospital and hospice services.
Medicare Part B covers outpatient services
Medicare Part C is alternative to the other parts intended to allow experimentation with differently structured plans in an effort to reduce costs to government and allow patients to choose plans with more benefits.
Medicare Part D covers self-administered prescription drugs
Medicaid in the United States is a social health care program for families and individuals with limited resources. The Health Insurance Association of America describes Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care". Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (as of 2017). It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.
The Patient Protection and Affordable Care Act ("Obamacare") significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards.
Tricare (TRICARE), formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), was a health care program of the United States Department of Defense Military Health System. Tricare povided civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. The Tricare program was managed by Tricare Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs). Tricare was the civilian care component of the Military Health System, although historically it also included health care delivered in the military medical treatment facilities.
Please view the videos below:
Optional reading assignment:
Understanding Health Insurance, by Green and Rowell. 10th Edition)
Read "Introduction", page 148-149
Read "Medicare Claims Instructions" page 472
Read and study "CMS 1500 Form for Medicare" (Table 14-4) pages 472-475.
Read and study "CMS 1500 form for Medicaid" (Table 15-1) pages 506-507
Read and study "CMS 1500 form for Tricare" (Table 16-4) pages 540-543