Week 2 msn 603
- 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
- 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