Who Pays the Bills

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By Mario Apontes Ruiz

MEDICARE
y The Social Security Act of 1965 was signed into law on

July 30, 1965, by President Lyndon B. Johnson. This legislation included the establishing of the Medicare program. At the bill-signing ceremony, Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card, and Truman's wife Bess, the second

MEDICARE
y Medicare is a social insurance program administered

by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria

MEDICARE
y Before Medicare, only 51% of people aged 65 and older

had health care coverage, and nearly 30% lived below the federal poverty level. "Original Medicare" cover 80% of the Medicare-approved amount of any given medical cost.

MEDICARE
y the remaining 20% of cost must be paid by either a

Medicare Supplement plan or out-of-pocket via the patient's own personal funds (check, money order, cash, etc.) y The Medicare program also funds residency training programs for the vast majority of physicians in the United States.

MEDICARE
y Medicare is financed by payroll taxes imposed by the

Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment, out of pocket

MEDICARE
y Eligibility y In general, all persons 65 years of age or older who

have been legal residents of the United States for at least 5 years are eligible for Medicare. People with disabilities under 65 may also be eligible if they receive Social Security Disability Insurance (SSDI) benefits.

MEDICARE
y Part A: Hospital Insurance y Part B: Medical Insurance y Part C: Medicare Advantage plans y Part D: Prescription Drug plans

MEDICAID
y Medicaid was created on July 30, 1965, through Title

XIX of the Social Security Act. Each state administers its own Medicaid program while the federal Centers for Medicare and Medicaid Services (CMS) monitors the state-run programs .

MEDICAID
y Medicaid is the United States health program for

certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states

MEDICAID
y Poverty alone does not necessarily qualify someone for

Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States.

MEDICAID
y The main criterion for Medicaid eligibility is limited

income and financial resources, a criterion which plays no role in determining Medicare coverage

State Children s Health Insurance Program (S-CHIP
y Supplements Medicaid by covering low-income

children who are ineligible for Medicaid y Administered and financed similarly to Medicaid y Similar problems to Medicaid:
y Low reimbursement rates

some providers refuse to

accept S-CHIP y Under-enrollment y Eligibility varies by specific populations

Veterans Health Administration
y Health benefits plan available to all veterans y Services delivered through VA health care facilities

( socialized medicine ) y Financed by the federal government

Employer-sponsored insurance
y Offered by employers as part of benefits package y Administered by private insurance companies (for-

profit and non-profit) remainder

y Employer pays bulk of premium; employee pays

Individual insurance
y Purchased directly by people who do not get

coverage through their employers
y Non-group (individual) plans
y Premiums based on individual health risk y High-risk individuals with limited access

y Administratively expensive

y HMO require members to select a primary care

physician (PCP), a doctor who acts as a "gatekeeper" to direct access to medical services. PCPs are usually internists, pediatricians, family doctors, or general practitioners (GPs). Excepting medical emergency, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary

y PPO (preferred provider organization) is a

managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients

y EPO: An exclusive provider organization (EPO) is a

type of managed care plan that combines features of HMOs and PPOs. It is referred to as exclusive because the employers agree not to contract with any other plan

Coverage
Uninsured 18%

Medicaid/ Other Public 15% Employersponsored 62%

Private Nongroup 5%

Profile of the uninsured
y 47.0 million Americans y 81% from working families y 52-59% from low-income families (200% FPL) y 80% are adults y 50% are ethnic minorities y 79% are American citizens

Source: Kaiser Commission on Medicaid and the Uninsured Source: US Census Bureau

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