In the United States, Medicare is a national health insurance program, which is now administered by the US federal Government's Medicaid and Medicare Service Centers but started in 1966 under the Social Security Administration. Medicare USA is funded by a combination of payroll taxes, premiums and additional taxes from beneficiaries, and general revenue. It provides health insurance for Americans aged 65 and older who have worked and paid into the system through payroll taxes. It also provides health insurance for young people with certain disability status as determined by the Social Security Administration, as well as those with end-stage kidney disease and amyotrophic lateral sclerosis.
In 2015, Medicare provides health insurance for more than 55 million - 46 million people aged 65 and older and 9 million young people. On average, Medicare covers about half of the health care costs for those enrolled. Applicants must then cover the remainder of their costs with additional insurance, separate insurance, or get out of the bag. The costs outside the pockets may vary depending on the amount of medical care needed by the medical personnel. These out-of-pocket costs may include deductibles and co-pay; undisclosed service costs - such as long-term care, dental, hearing, and vision - and additional insurance premiums.
Medicare is subdivided into parts A and B - Medicare Part A includes hospitals (hospitalization, officially recognized only), skilled nursing (only after officially accepted for three days and not for custodial care), and hospital services; Part B includes outpatient services including some service providers during hospitalization. Part D includes prescribed prescription drugs. Part C is an alternative called Managed Medicare by Supervisors that allows patients to choose a plan with at least the same benefits as Part A and B (but most often more), often a benefit from Part D, and always spend an annual allowance restricting shortages A and B; the recipient must register in Parts A and B first before applying for Part C.
Video Medicare (United States)
Riwayat program
The name "Medicare" was originally given to a program that provides medical care to families of individuals serving in the military as part of the Tangguh Medical Treatment Act, passed in 1956. President Dwight D. Eisenhower held the first White House Conference on Aging in January 1961 , where creating a health care program for recipients of social security guarantees is proposed. In July 1965, under the leadership of President Lyndon Johnson, Congress passed Medicare under Title XVIII of the Social Security Act to provide health insurance for people aged 65 and older, regardless of income or medical history. Johnson signed the bill into law on July 30, 1965 at Harry S. Truman's Presidential Library in Independence, Missouri. Former President Harry S. Truman and his wife, former First Lady Bess Truman became the first recipients of the program. Before Medicare was created, about 60% of people over age 65 had health insurance, with coverage often unavailable or unaffordable by many others, as older adults pay more than three times as much for health insurance as younger people. Many of these latter groups (about 20% of total by 2015) become "double qualified" for Medicare and Medicaid by passing legislation. In 1966, Medicare spurred racial integration of thousands of waiting rooms, hospital floors, and physician practices by making payments to healthcare providers dependent on desegregation.
Medicare has been in service for half a century and, during that time, has undergone several changes. Since 1965, program provisions have been extended to include benefits for speech, physical, and chiropractic therapy in 1972. Medicare added payment options to health care organizations (HMOs) in the 1980s. Over the years, Congress expanded Medicare eligibility to younger people with permanent disability and received Social Security Assurance (SSDI) payments and those with end-stage renal disease (ESRD). The relationship with the HMO began in 1980 formalized under President Bill Clinton in 1997 as Medicare Part C (although not all parts of the C health plan plan must be HMO, about 75% are). In 2003, under President George W. Bush, the Medicare program to cover virtually all prescribed self-administered drugs (and came into effect in 2006) as Medicare Part D (previously and still, professionally managed medications such as chemotherapy but even annual flu shot injection included in Part B).
The government added hospital allowances to help parents temporarily in 1982, and made this permanent in 1984. The Congress expanded Medicare in 2001 to cover young people with amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease).
Maps Medicare (United States)
Administration
The Medicare and Medicaid Service Center (CMS), a component of the US Department of Health and Human Services (HHS), manages Medicare, Medicaid, Children's Health Insurance Program (CHIP), Clinical Laboratory Enhancement Amendment (CLIA) Act on Affordable Care (ACA) ("Obamacare"). Along with the Department of Labor and Treasury, the CMS is also implementing the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and most aspects of the Affordable Care Act of 2010 as amended. The Social Security Administration (SSA) is responsible for determining Medicare eligibility, eligibility for and payment of Extra/Low Income Assistance Payments related to Part D Medicare, and collecting some premium payments for the Medicare program.
Head of Actuaries of CMS must provide accounting information and cost projections to the Medicare Supervisory Board to assist them in assessing the financial health of the program. The Council is required by law to publish an annual report on the financial status of the Medicare Trust Fund, and the reports shall include a statement of actuarial opinion by the Actuary Chairman.
Since the Medicare program began, CMS (which is not always the responsible bureaucratic name) has contracted private insurance companies to operate as an intermediary between government and medical providers to manage Part A and Part B benefits. The contracted process includes claims and payment processing, call center services, doctor registration, and fraud investigation. Starting in 1997 and 2005, respectively, this, together with other insurance companies and other companies or organizations (such as integrated delivery systems or union health workers), also began to manage Part C and Part D plans.
The Special Relevant Value Relative Scale Update Committee (or Relative Value Reform Committee, RUC), consisting of physicians associated with the American Medical Association, advises governments on wage standards for Medicare care procedures performed by doctors and other professionals under Medicare Section B. A but different CMS systems determine the level of acute care and other hospitals - including skilled care facilities - under Medicare Part A.
Financing
Medicare has several sources of financing.
Part A hospitalized hospitalized hospitals and skilled maintenance are mostly funded by income from the 2.9% wage tax levied on employers and workers (each paying 1.45%). As of December 31, 1993, the law provides the maximum amount of compensation in which Medicare tax may be imposed annually, in the same way as the Social Security taxes work in the US. Beginning January 1, 1994, the limit of compensation has been removed. Individual entrepreneurs have to pay a whole tax of 2.9% on net self-employment (because they are both employees and employers), but they can deduct half of the tax from income in calculating income taxes. Beginning in 2013, the rate of Part A Tax on income earned exceeding US $ 200,000 for individuals (US $ 250,000 for married couples applying jointly) rose to 3.8%, to pay a portion of the subsidy fee mandated by the Undang- Affordable Care Act.
Parts B and D are financed in part by premiums paid by Medicare registries and general fund revenues. In 2006, additions were added to Part B premiums for higher-income seniors for part of Part D funds. Under the Affordable Care Act Act of 2010, other additions are then added to Part D premiums for seniors with higher incomes for a portion fund the Affordable Care Act and the number of Part B beneficiaries charged in 2006 additional taxes are doubled, also in part to fund PPACA.
Parts A and B/D use separate trust funds to receive and disburse the funds mentioned above. Part C uses these two trust funds in proportion as determined by the CMS which reflects how Part C is fully beneficiary in Part A and B of Medicare, but how their medical needs are paid per capita rather than "cost for service" (FFS)).
In 2015, Medicare spending accounts for about 15% of total US Federal spending. This share is projected to exceed 17% by 2020.
The Baby Boom Generation Pension - which by 2030 is projected to increase enrollment to more than 80 million as the number of workers per enrollee decreases from 3.7 to 2.4 - and the rising cost of overall health care in the country poses a huge financial challenge to the program. Medicare spending is projected to increase from $ 523 billion in 2010 to over $ 1 trillion by 2022. Baby-boomer health is also an important factor: 20% have five or more chronic conditions, which will add to future health care costs. In response to these financial challenges, Congress made major cuts to future payments to providers as part of PPACA in 2010 and Medicare Access and the CHIP Reauthorization Act of 2015 (MACRA) and policy makers have offered many competing proposals to further reduce Medicare costs.
Nearly one in three dollars spent on Medicare flows through one of several cost reduction programs. Cost reductions are influenced by factors including reductions in inappropriate and unnecessary care by evaluating evidence-based practices and reducing unnecessary, duplicative, and inappropriate amounts of care. Cost reductions can also be made by reducing medical errors, investing in health care information technology, increasing data transparency and quality of data, improving administrative efficiency, and by developing both clinical/non-clinical guidelines and quality standards.
Feasibility
In general, anyone 65 years or older who has been an official resident of the United States for at least five years is eligible for Medicare. Persons with disabilities under 65 can also qualify if they receive Social Security Assurance (SSDI) allowances. Certain medical conditions can also help people become eligible to enroll in Medicare.
People are eligible for Medicare coverage, and Medicare Part A premium is entirely exempt, if the following circumstances apply:
- They are 65 years of age or older and US citizens or have been permanent legal residents for five consecutive years, and them or their spouses ( or former partner qualification) has paid Medicare tax for at least 10 years.
- or
- They are under 65 years of age, disabled, and have received Social Security Security benefits or disability benefits of the Railway Retirement Board; they must receive one of these benefits for at least 24 months from the date of entitlement (eligibility for the first disability payments) before being eligible to enroll in Medicare.
- or
- They continue dialysis for end-stage kidney disease or need a kidney transplant.
Those 65 and older who choose to enroll in Part A Medicare must pay a monthly premium to remain enrolled in Medicare Part A if they or their partner have not paid eligible Medicare salary taxes.
People with disabilities who receive SSDI qualify for Medicare while they continue to receive SSDI payments; they lose eligibility for Medicare based on disability if they stop receiving SSDI. A 24-month exclusion means the person with disability has to wait two years before receiving government health insurance, unless they have one of the listed diseases. The 24 month period is measured from the date that a person is determined to qualify for SSDI payments, not necessarily when the first payment is actually received. Many new SSDI recipients receive "back" defect payments, covering the period usually starting six months from the beginning of disability and ending with the first monthly SSDI payment.
Some beneficiaries have two conditions. This means they are eligible for Medicare and Medicaid. In some states for those earning less, Medicaid will pay Part B premiums for beneficiaries (most beneficiaries have been working long hours and have no Part A premiums), as well as some of their medical expenses and pocket hospitals.
Benefits and sections
Medicare has four parts: Part A is Hospital Insurance. Part B is Health Insurance. Medicare Part D includes many prescription drugs, although some are covered by Part B. In general, the difference is based on whether the drug itself or not. Part C of the health plan, the most popular of which is the branded Medicare Advantage, is another way for Original Medicare recipients (Parts A and B) to receive the benefits of Parts A, B and D them (basically Part C is a public supplement option that can compared to the additional private group Medicare coverage of a former employer or personal purchased personal insurance called Medigap). All Medicare benefits depend on your medical needs.
The original program included Sections A and B. A C-like plan had existed as a pilot project in Medicare since the early 1980s but the Part was formalized by law 1997. (Simply put, Part C is a premium support program similar to insurance reform including in Patient Protection and the Affordable Care Act of 2010 as amended and similar to the way almost all insurance-sponsored companies work in the United States). Part D was introduced January 1, 2006.
Part A: Hospital/hospital insurance
Part A includes inpatient hospitals where the beneficiaries have been formally admitted to the hospital, including semi-private rooms, food, and tests. On January 1, 2018, Medicare Part A has an inpatient hospital minus $ 1340, coinsurance per day for $ 335 after 61 days of confinement in one "disease spell", coinsurance for "lifetime reserves" (basically days 91-150 ) $ 670 per day, and coinsurance in Skilled Nursing Facility (following the medically required medical breakdown of 3 consecutive nights or more) for 21-100 days from $ 167.50 per day (up to 20 days from SNF confinement not have co-pay) This amount increases or decreases every year on the first day of the year.
Maximum duration of stay Medicare Part A covers in inpatient hospitalization or a series of stays typically 90 days. The first 60 days will be paid by Medicare in full, with the exception of one copay (also and more commonly referred to as a "deductible") at the beginning of 60 days from $ 1340 in 2018. The 61-90 days require joint payments of $ 335 per day by 2018. Beneficiaries are also allocated a "lifetime reserve day" that can be used after 90 days. These lifetime reserves require payments of $ 670 per day by 2018, and recipients can only spend a total of 60 days during their lifetime. A new collection of 90 days in hospital, with new payments of $ 1340 in 2018 and $ 335 per day for 61-90 days, begins only after beneficiaries have 60 days continuously without payment from Medicare for hospitals or Treatment facilities Well groomed.
Some "hospital services" may be performed as inpatient services, which will be replaced under Part A; or as an outpatient service, to be replaced, not under Part A, but under Part B instead. The "Two-Midnight Rule" decides which one. In August 2013, the Medicare and Medicaid Service Center announces the final rule on eligibility for effective hospital inpatient services October 1, 2013. Under a new rule, if a physician recognizes Medicare recipients as an inpatient in the hope that patients will need hospital care which "crosses two midnights," Medicare Part A payment is "generally appropriate." However, if it is anticipated that patients will require hospitalization for less than two hours midnight, Medicare Part A payments are generally not appropriate; payments as approved will be paid on the basis of Section B. The time patients spent in the hospital before admission is officially ordered is considered an outpatient. However, hospitals and physicians may consider pre-hospital admission times when determining whether patient care would be expected to cross two midnights to be discussed under Part A. In addition to deciding the trust funds used to pay for various outpatient costs versus inpatient care, the number of days in which a person is officially regarded as a patient claiming to affect eligibility for Part A of a skilled nursing service.
Medicare penalizes the hospital for readmissions. After making initial payments for hospitalization, Medicare will take back from the hospital this payment, plus a penalty of 4 to 18 times the initial payment, if the number of patients above the average of the hospital received back within 30 days. These re-enactment sanctions apply after some of the most common treatments: pneumonia, heart failure, heart attack, COPD, knee replacement, hip replacement. A study of 18 countries conducted by the Agency for Health Research and Quality (AHRQ) found that 1.8 million Medicare patients aged 65 and older were reinstated within 30 days of early hospital stay in 2011; conditions with the highest receptivity rates are congestive heart failure, septicemia, pneumonia, and chronic obstructive pulmonary disease and bronchiectasis.
The highest penalty in the hospital is charged after knee or hip replacement, $ 265,000 per admission back. The goal is to encourage better post-hospital care and more referrals to care home and late-life care as a substitute for treatment, while the effect is also to reduce coverage in hospitals that care for poor and vulnerable patients. Total fines for grasses above the average in 2013 are $ 280 million, for 7,000 registration surpluses, or $ 40,000 for each return again above the US average.
Part A fully includes short visits to rehabilitation or recovery at skilled care facilities and up to 100 days per medical need by co-paying if certain criteria are met:
- Stay in the hospital in advance should be at least three days as an inpatient, three times midnight, not including the exit date.
- Care in a nursing home should be for something diagnosed during a hospital stay or for a major cause of hospital stay.
- If the patient does not receive rehabilitation but has some other disease requiring skilled nursing supervision then the nursing home will be closed.
- Care provided by a nursing home should be skilled. Medicare section A does not pay only that only only provides custodial, non-skilled, or long-term care, including daily living (ADL) activities such as personal hygiene, cooking, cleaning, etc.
- Treatment should be medically necessary and the progression of some designated plans should be made on some schedule as determined by the physician.
The first 20 days will be fully paid by Medicare with the remaining 80 days requiring a joint payment of $ 167.50 per day by 2018. Many retired insurance groups, Medigap and Part C insurance plans have provisions for additional coverage of skilled care concerned about the policies they are selling. If the beneficiary uses part of their Part A benefit and then leaves at least 60 days without receiving facility-based facilities, 90-day hospital hours and 100-day nursing home hours are reset and the person is eligible for a new benefit period.
Hospital allowances are also provided under Part A of Medicare for severely ill persons with less than six months to live, as determined by the patient's physician. The severely ill person should sign a statement that hospital care has been selected to exceed other Medicare benefits (eg assisted care or hospital care). The treatments provided include pharmaceutical products to control symptoms and pain relief as well as other services not covered by Medicare such as grief counseling. Hospice is covered 100% without co-pay or deducted by Medicare Part A except that the patient is responsible for copay for outpatient medication and quiet treatment, if required.
Part B: Medical insurance
Part B health insurance helps pay for some services and products not covered by Section A, generally in outpatients (but also when under unadegated observation status in hospitals). Part B is optional. This is often suspended if the recipient or spouse is still working and has group health coverage through the employer. There is a life sentence (10% per annum on premium) charged for not registering in Part B when first eligible or otherwise covered by the Veterans Health Administration program.
Part B coverage begins after a patient meets his deductible ($ 183 for 2017), then Medicare typically covers 80% of the RUC-set rate for approved services, while the remaining 20% ​​is the responsibility of the patient, either directly or indirectly. by a retired private group or Medigap insurance.
Part B includes the services of patient physicians, guest nurses and other services such as x-rays, laboratory tests and diagnostics, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, hospital outpatient procedures, limited ambulance transport, immunosuppressive drugs for organ transplant recipients , chemotherapy, hormonal treatments such as Lupron, and other outpatient medical care provided at the doctor's office. It also includes chiropractic care. Drug administration is covered in Part B if administered by a doctor during an office visit.
Part B also assists with durable medical equipment (DME), including sticks, walkers, lift chairs, wheelchairs and mobility scooters for those with limited mobility. Prosthetic devices such as prosthetic limbs and breast prostheses after mastectomy, as well as a pair of glasses after cataract surgery, and oxygen for home use are also covered.
The complex rules control the benefits of Part B, and the published suggestions periodically represent coverage criteria. At the national level, this advisor is issued by CMS, and is known as National Coverage Determinations (NCD). Local LCD Coverage (LCD) applies within the multi-country territory managed by certain Medicare Part B regional contractors, and the Local Medical Review Policy (LMRP) replaced by LCDs in 2003. The coverage information is also located in CMS Internet-Only Manuals ( IOM), Federal Regulatory Code (CFR), Social Security Act, and Federal Register.
Monthly Premiums for Part B for 2016 are $ 121.80 per month but everyone in Social Security 2015 is "harmless" (from the fact that Social Security does not go up in 2016) and only pays $ 104.90 a deductible premium monthly in 2015, with additional income-additional costs for those with revenues of more than $ 85,000 per year.
Bagian C: Paket Medicare Advantage
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were formally given the option of receiving their Original Medicare allowance through a S-C capitalized health insurance package, rather than through the Original fee for Medicare payment system services. Many previously had the option through a series of demonstration projects that began in the early 1980s. This Part C Plan was originally known as the "Medicare Choice". In the Medicare Modernization Act of 2003, most of the Medicare Choice plans were re-listed as "Medicare Advantage" (MA) plans (though MA is a government term and may not be seen by the beneficiaries of the C Health Section package). Other types of plans, such as the 1876 Cost plan, are also available in restricted areas of the country. The cost plan is not a Medicare Advantage plan and is not capitalized. Instead, beneficiaries continue to receive their Original Medicare benefits while their sponsors manage the benefits of Part A and Part B them. Sponsorship of Plan C may be an integrated health delivery system, unions, religious organizations, insurance companies or other types of organizations.
General Section C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards established by the Original Medicare but they do not necessarily include every benefit in the same way. Upon approval by the Medicare and Medicaid Service Centers, if the Part C package chooses to pay less than the Original Medicare for some benefits, such as Maintenance Treatment Facility care, savings can be forwarded to the consumer by offering lower joint payment for doctor visits.
â € Å"Medicare Parts A and B Asliâ € â„¢ have a standard benefit package covering the necessary medical care as described in the above section that members of almost all hospitals or physicians in the country can receive (if the doctor or hospital receives Medicare). Original Medicare recipients who choose to enroll in the Part C Medicare Advantage health plan instead of not giving up their rights as Original Medicare recipients receive the same standard benefits - at a minimum - as provided in the Original Medicare, and earn an out of pocket (OOP) annual income top expenses are not included in Original Medicare. However they should usually only use certain provider networks except in emergencies, usually limited to the area around their official residence (which can vary from tens to more than 100 miles depending on the region). Most of the C plan sections are traditional HMOs that require patients to have primary care physicians, though others are preferred provider organizations (which usually mean unlimited provider restrictions such as with HMO), and some actually charge for hybrid services.
General C Medicare Members Members of the health benefits package usually also pay monthly premiums in addition to Medicare Part B premiums to cover items not covered by traditional Medicare (Parts A & B), such as OOP limits, self-regulated prescription drugs, dental care , vision care, annual physical, coverage outside the United States, and even sports or health club membership and - and perhaps most importantly - reduced 20% of the joint and high deductible payments associated with the Original Medicare. But in some situations, the benefits are more limited (but can not be more limited than the Original Medicare and should always include OOP limits) and no premium. In some cases, sponsors may even rebate some or all of the premiums of Part B, although this type of Part C plan becomes scarce.
Prior to 2003, Section C plans to become a suburban HMO tied to a large nearby educational hospital that costs equal to or even 5% less than the cost to cover the medical needs of comparable beneficiaries in Medicare Asli. The 2003 paying/bidding/formula reward framework compensates parts of C plan of 7 percent (2009) on a national average compared to what the original Medicare recipient cost per person averages nationally that year and as much as 5 percent (2016) less nationally in other years (see last year's Medicare Supervisory Report, Table II.B.1). The MedPAC group found within one year the comparative difference for "beneficiaries" (not all beneficiaries as described in the first sentence) was as high as 14% and tended to average about 2% higher. The word as in the previous sentence is the key. The objective of both the laws of 1997 and 2003 is that the difference between the cost of services and the beneficiaries of prolonged costs will reach parity over time.
The 2003 payment formula succeeded in increasing the percentage of poor in rural and urban poor who could benefit from the OOP limit and lower costs and dedication - as well as coordinated medical care - linked to Part C. But in practice, a set of Medicare recipients received more many benefits than others. The difference caused by the 2003 law payment formula is almost completely eliminated by the PPACA and has been virtually completely removed in accordance with MedPAC 2018's annual report, March 2018. One special remuneration program formula remaining - designed primarily for unions who want to sponsor Part C - is being removed starting in 2017. In 2013 and since then, the average recipient cost of the Medicare Trust Fund Part 2% -5% less than the heirs on traditional charges for Medicare services, completely reversing the situation in 2006-2009 after the implementation of the law Invite 2003 and recover capital costs vs. fees for the balance of service funds to the appropriate level of parity.
Registration in Part C public health plans, including the Medicare Advantage plan, grew from approximately 10% of total enrollment in 2005 to about 35% by 2018. Almost all Medicare beneficiaries have access to at least two public Medicare Part C plans; most have access to three or more.
Bagian D: Rencana obat resep
Medicare Part D shall enter into force on 1 January 2006. Anyone with Part A or B is eligible for Part D, which covers most self-administered drugs. This is made possible by the passage of the Medicare Modernization Act of 2003. To receive this benefit, a person with Medicare must enroll in a Prescription Drug Plan (PDP) or a stand-alone Medicare Advantage plan with integrated prescription drug coverage (MA-PD). ). These plans are approved and regulated by the Medicare program, but are actually designed and managed by private health insurance companies and pharmaceutical benefit managers. Unlike Original Medicare (Parts A and B), the coverage of Part D is not standard (though it is governed by the Medicare and Medicaid Service Centers). Plan to choose which drugs they want to cover (but should include at least two drugs in 148 different categories and cover all or "substantially all" drugs in the following class of drugs: anti-cancer, anti-psychotic, anti-seizure, anti-drug suppressors of depression, immuno-suppressant, and HIV and AIDS). Plans can also determine with the CMS approval at which level (or level) they want to cover, and are encouraged to use gradual therapy. Some drugs are not covered in coverage at all and Part D plans that include excluded drugs are not permitted to pass those costs to Medicare, and plans are required to pay CMS if they are known to have been charged Medicare in this case.
Under the 2003 law that created Medicare Part D, the Social Security Administration provides extra extensive assistance to low-income seniors so there is virtually no drug cost; In addition, about 25 countries offer additional assistance above Part D. It should be noted again for eligible dual beneficiaries (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by Part D Medicare. Most of this assistance for low-income seniors is available to them through other programs before Part D is implemented.
Out-of-pocket costs
No part of Medicare pays all medical expenses incurred by the beneficiaries and many fees and services are not covered at all. The program contains premiums, deductibles and coinsurance, which the individuals covered must pay out-of-pocket. A study published by the Kaiser Family Foundation in 2008 found the Medicare Fee-for-Service benefits package less favorable than other large companies. Preferred provider organization plan or Federal Employees Health Benefits Program Standard Option. Some people may be eligible to have other government programs (such as Medicaid) pay a premium and some or all of the costs associated with Medicare.
Premium
Most Medicare registrants do not pay Part A's monthly premium, because they (or spouses) have 40 or more 3 months in which they pay the Federal Insurance Contributions Act tax. The profits are the same no matter how many or few receivers are paid as long as the minimum number of quarters is reached. Medicare qualified persons who do not have 40 or more quarters of Medicare-protected jobs can purchase into Part A for an adjusted annual monthly premium:
- $ 248.00 per month (as of 2012) for those with 30-39 Medicare-protected workstations, or
- $ 451.00 per month (per 2012) for those with less than 30-quarters of Medicare-protected work and who are not eligible for Part A premium protection.
Most of the Medicare Part B that follows it pay insurance premiums for this coverage; Premium Part B standard for 2013 to 2015 is $ 104.90 - $ 335.70 per month. Premiums increase to over $ 120 per month by 2016 but only for those who are not Social by 2015. The new revenue-based premium surtax scheme has been in effect since 2007, where premium Part B is higher for beneficiaries with earnings exceeding $ 85,000 for individuals or $ 170,000 for married couples. Depending on the extent to which the recipient's income exceeds the base income, this higher Part B premium is $ 139.90, $ 199.80, $ 259.70, or $ 319.70 for 2012, with the highest premium being paid by the individual earning over $ 214,000, or married couples earning more than $ 428,000.
Medicare Premium Part B is usually deducted automatically from the beneficiary's monthly Social Security check. They can also be paid quarterly through bills sent directly to the beneficiaries. This alternative is becoming more common because although the age of eligibility for Medicare remains at 65 per law of 1965, the so-called Full Pension Age for Social Security has been upgraded to 66 and will be increasing from time to time. Therefore, many people postpone the collection of Social Security and must pay their Part B premium directly.
Section C plans may or may not charge a premium (almost all), depending on the draft plan as approved by the Medicare and Medicaid Service Center. Part D premiums vary by benefit level.
Deductible and coinsurance
Section A - For each benefit period, the recipient pays for each adjusted year:
- Part A is deducted from $ 1,288 in 2016 and $ 1,316 on 2017 for a 1-60 day hospital stay.
- A combined fund of $ 322 per day in 2016 and $ 329 a joint payment in 2017 for 61-90 days of hospital stay.
- Co-pay payments of $ 644 per day in 2016 and $ 658 co-pay in 2017 for 91-150 days of hospital stay, as part of from their limited Lifetime Day Reservation.
- All charges for every day above 150 days
- Insurance for Skilled Care Facilities is $ 161 per day in 2016 and $ 164.50 in 2017 for 21 to 100 days for each benefit period (none joint payment for the first 20 days).
- Blood subtracted from the first 3 liters of blood required in a calendar year, unless replaced. There are 3-pint blood deductibles for both Part A and Part B, and these separate deductibles do not overlap.
Part B - Once the beneficiary meets an annual reduction of $ 183.00 for 2017, they will be required to pay co-insurance of 20% of the Medicare approved amount for all services covered by Part B with the exception of most lab services, covered in 100% - and outpatient mental health, currently (2010-2011) covered in 55% (45% copay). The copay for outpatient mental health, which starts at 50%, gradually decreases over the next few years to match the 20% required for other services. They are also required to pay an excess fee of 15% for services provided by doctors who do not accept the assignment.
The cost of deductibles, co-pay, and coinsurance for parts C and D vary from plan to plan. All Package C includes annual expenditure expenditure (OOP) annually. Genuine Medicare does not include OOP limits.
Medicare supplement (Medigap) policy
Medicare recipients who are not eligible for Medicare (about 20%) and Medicaid or who do not receive additional insurance through a former employer (40%) or public Part C Medicare Advantage health plan (approximately 30%), almost all choose to purchase additional types of insurance personally, called Medigap's plan (20%), to help fill the financial hole in the Original Medicare (Parts A and B). Note that percentages add up to more than 100% because many beneficiaries have more than one type of supplement. This Medigap insurance policy is standardized by CMS, but is sold and managed by private companies. Some Medigap policies that were sold before 2006 may include protection for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs. Medicare regulations prohibit Medicare recipients from being sold in both the public Part C Medicare Advantage healthcare package and the personal Medigap Policy. Like the public Part C health plan, private Medigap policies are only available to registered beneficiaries to benefit from Medicare Part A and Part II B. This policy is regulated by the state insurance department rather than the federal government even though the CMS outlines what various Medigap plans should include minimal. Therefore, Medigap's type and pricing policies vary widely from state to state and underwriting levels, open enrollment and guaranteed issues also vary widely from state to state.
By 2016, 11 policies are currently on sale - although only a few are available in all states, and some are not available at all in Massachusetts, Minnesota and Wisconsin Medicare Supplement Plans are based on a base and a series of riders. These are Package A, Plan B, Plan D, Plan D, Plan F, High Deductible Plan F, Plan G, Plan K, Plan L, Plan M, and Plan N. Costs are usually the only difference between Medigap's policy and the same letter sold by insurance companies different. Unlike Medicare Advantage Plans, Medicare Supplement Plans has no network, and every provider receiving Medicare must also receive a Medicare Supplement Plan.
All insurance companies that sell Medigap policies are required to make Plan A available, and if they offer other policies, they must also make Plan C or Plan F available, even though Plan F is scheduled to expire in 2020. Whoever currently has a Plan F may save it.
Payment for services
Medicare contracts with regional insurance companies to process over one billion fee-for-service claims per year. In 2008, Medicare accounted for 13% ($ 386 billion) of the federal budget. By 2016 it is projected to reach nearly 15% ($ 683 billion) of total expenditure. During the 2010-2019 decade Medicare is projected to cost 6.4 trillion dollars.
Reimbursement for Service Part A
For institutional care, such as hospitals and nursing homes, Medicare uses a prospective payment system. In a prospective payment system, health care institutions receive a set amount of money for each episode of care given to the patient, regardless of the actual number of treatments. The actual allocation of funds is based on the list of groups associated with the diagnosis (DRG). The actual amount depends on the actual main diagnosis made in the hospital. There are some issues surrounding the use of DRG by Medicare because if patients use less care, the hospital should keep the rest. This, in theory, has to balance the costs for the hospital. However, if the patient uses more care, then the hospital must cover its own losses. This results in an "upcoding problem," when a doctor makes a more severe diagnosis to protect himself against accidental costs.
Reimbursement for Service Part B
Payments for medical services under Medicare have grown since the program was created in 1965. Initially, Medicare paid physician compensation based on doctor's fees, and allowed doctors to bill Medicare recipients in amounts that exceed Medicare reimbursements. In 1975, the annual increase in physician costs was limited by the Medicare Economic Index (MEI). MEI is designed to measure changes in time costs and operating costs of physicians, adjusted for changes in physician productivity. From 1984 to 1991, annual changes in fees were determined by law. This is done because doctors' fees go up faster than projected.
The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. First, it introduced the Medicare Fee Schedule, which came into effect in 1992. Second, limiting the number of Medicare non-providers can balance Medicare recipients' bills. Third, introducing Medicare Volume Performance Standards (MVPS) as a way to control costs.
On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS), a list of approximately 7,000 billable services. Each service is priced in a Relatively Resource Based Scale (RBRVS) with three Relative Unit Values ​​(RVUs) that largely determine the price. Three RVUs for each procedure are geographically weighted and the weighted RVU value multiplied by the Global Conversion Factor (CF), yielding the price in dollars. RVU itself was largely decided by a private group of 29 physicians (mostly specialists) - Relative Value Relative Society Committee of the Association of American Medical Associations (RUC).
From 1992 to 1997, adjustments to physician payouts were adjusted using MEI and MVPS, which essentially attempted to offset the increased volume of services provided by physicians by lowering their replacement per service.
In 1998, Congress replaced the VPS with Sustainable Growth Rate (SGR). This is done because the payment rates vary greatly under MVPS. SGR seeks to control spending by setting annual and cumulative spending targets. If the actual spend for a given year exceeds the targeted spending for that year, the replacement rate is adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVU.
In 2002, the payment rate was cut by 4.8%. In 2003, the payment rate was scheduled to be reduced by 4.4%. However, Congress increased the cumulative SGR target in the 2003 Consolidated Settlement Resolution (P.L. 108-7), allowing payments for medical services to rise 1.6%. In 2004 and 2005, the repayment rate was scheduled to be reduced. The Medicare Modernization Act (P.L. 108-173) increased the 1.5% payment for the two years.
In 2006, the SGR mechanism was scheduled to lower the payment of physicians by 4.4%. (This amount is the result of a 7% drop in doctor payments times a 2.8% increase in inflation adjustment.) Congress overrides this decline in the Deficit Reduction Act (P.L. 109-362), and holds physician payments in 2006 at their 2005 level. Similarly, other congressional actions held in 2007 payments at the 2006 level, and HR 6331 held 2008 doctor payments for their 2007 level, and provided for a 1.1% increase in physician payments in 2009. Without continuing further congressional intervention, SGR is expected to decrease doctor's payment from 25% to 35% over the next few years.
MFS has been criticized for not paying enough doctors for its low conversion factor. With adjustments to the MFS conversion factor, it is possible to make global adjustments in payments to all doctors.
SGR is the subject of a possible reform legislation by 2014. On March 14, 2014, the United States House of Representatives adopted the SGR and Medicare 2014 Modernization Payment Delivery Act (HR 4015; 113th Congress), a bill that would have replaced formula (SGR) with a new system to establish the rate of payments. However, the bill will pay for these changes by delaying the mandate requirements of individual Affordable Care Act, a proposal that is not very popular with Democrats. SGR is expected to lead to a 24 percent Medicare payment cut on April 1, 2014, if a solution to reform or delay SGR is not found. This led to another bill, the 2014 Medicare Access Protection Act (H.R. 4302; 113th Congress), which will delay the cuts until March 2015. The bill is also controversial. The American Medical Association and other medical groups oppose it, asking Congress to provide a permanent solution, not just another delay.
The SGR process is replaced by a new rule on the part of MACRA by 2015.
Provider participation
There are two ways for providers to get a replacement in Medicare. "Participate" providers receive "duty," meaning that they receive Medicare approved rates for their services as payment (typically 80% of Medicare and 20% of recipients). Some non-participating doctors do not take on duties, but they also treat Medicare registrants and are authorized to balance the bill no more than a small fixed amount above the Medicare-approved rate. A small number of doctors are "private contractors," which means they opt out of Medicare and refuse to accept Medicare payments at all. These doctors are required to inform patients that they will be responsible for the full cost of their services out of pocket before treatment.
While most providers receive Medicare duty, (97 percent for some specialties), and most doctors still receive at least some new Medicare patients, that number decreases. While 80% of doctors at the Texas Medical Association received new Medicare patients in 2000, only 60% did so in 2012. A study published in 2012 concluded that the Medicare and Medicaid Service Center (CMS) relies on the recommendation of an American Advisory Panel Medical Association. The study led by Dr. Miriam J. Laugesen, of the Columbia Mailman School of Public Health, and colleagues at UCLA and the University of Illinois, pointed out that for the services provided between 1994 and 2010, the CMS agreed with 87.4% of the committee's recommendations, known as RUC or the Relative Value Reform Committee.
Office drug replacement
Chemotherapy and other drugs issued at the doctor's office will be replaced in accordance with the Average Sale Price, a figure calculated by taking the total sale of drug dollars as the numerator and the number of units sold nationally as the denominator. The current cost-replacement formula is known as "ASP 6" because it replaces doctors on 106% of ASP medicines. Discounts and rebates of pharmaceutical companies are included in ASP calculations, and tend to reduce them. In addition, Medicare pays 80% of ASP 6, which is equivalent to 84.8% of the average cost of the actual drug. Some patients have additional insurance or can pay co-pay. Large amounts do not. This leaves a payment to the doctor for most drugs under "under water" conditions. ASP 6 replaced the Average Wholesale Price in 2005, after a front-page article New York Times 2003 drew attention to the inaccuracy of Average Wholesale Price calculations.
This procedure is scheduled to change dramatically in 2017 based on CMS proposals that are likely to be completed by October 2016.
Medicare 10 percent incentive payment
"Doctors in the Professional Disadvantage Areas of Geographic Health (HPSAs) and Regional Medical Scarcity (ILM) can receive incentive payments from Medicare, payments are made every three months instead of claim-claims, and handled by the respective Medicare operators."
Registration
Generally, if you have received Social Security payments, at the age of 65 you are automatically enrolled in Medicare Part A (Hospital Insurance). In addition, you are also automatically enrolled in Medicare Part B (Health Insurance). If you choose to receive Part B, you must pay a monthly premium to deposit it. However, you may postpone registration without penalty under certain circumstances, or with a fine under other circumstances.
Bagian A & amp; B
Part A Late Registration Determination If you do not qualify for Part A free of charge, and you do not purchase a premium-based Part A when you first qualify, your monthly premium may rise by 10% You have to pay a premium which is higher for twice the number of years you can have Part A, but not register. For example, if you qualify for Part A for 2 years but do not register, you must pay a higher premium for 4 years. Normally, you do not have to pay a fine if you meet certain requirements that allow you to register for Part A during the Special Registration Period.
Part B Late Registration Delay If you did not register for Part B when you first qualify, you may have to pay a penalty for late registration as long as you have Medicare. Your monthly premium for Part B can go up 10% for any 12 month full period you can have with Part B, but do not sign up for it. Normally, you do not pay a penalty for late registration if you meet certain requirements that allow you to register for Part B during a special enrollment period.
Comparison with personal insurance
Medicare is different from private insurance available to American workers as it is a social insurance program. The social insurance program provides legally guaranteed benefits to the entire population (under certain circumstances, such as old age or unemployment). These benefits are financed significantly through universal taxes. As a result, Medicare is the mechanism by which the state takes part of its citizens' resources to ensure the health and financial security of its elderly citizens or in terms of disability, helping them cope with enormous and unexpected health care costs. In its universality, Medicare is very different from private insurance companies, who have to decide who to pay for and what benefits are offered to manage their risk pool and guarantee their costs do not exceed the premium.
Since the federal government is legally obliged to provide Medicare benefits to older Americans and disabled people, it can not cut costs by limiting eligibility or benefits, except through a difficult legislative process, or by revising its interpretation of medical needs. Under the law, Medicare may only pay for "reasonable and necessary goods and services for the diagnosis or treatment of illness or injury or to improve the function of the limbs wrong", unless there are other legal authorizations for payment. Cutting costs by cutting benefits is difficult, but the program can also achieve a large economies scale in terms of the price it pays for health care and administration costs - and, as a result, private insurance costs have increased by nearly 60% more than Medicare since 1970. < soup> [Original research?] The growth in Medicare costs is now equal to GDP growth and is expected to remain under private insurance for the next decade.
Since Medicare offers legally-specified benefits, the coverage policy and payment rates are generally known, and all applicants are entitled to the same coverage. In the private insurance market, plans can be tailored to offer different benefits to different customers, enabling individuals to reduce coverage costs while taking risks for non-covered care. Insurers, however, have far fewer disclosure requirements than Medicare, and research shows that customers in the private sector can find it difficult to know what their policies cover. and at what cost. In addition, as Medicare collects data on utilization and costs for its registrants - data that are insured by the private sector as trade secrets - Medicare gives researchers key information about the performance of the health care system.
Medicare also has an important role in encouraging changes throughout the health care system. Because Medicare pays most health care in every country, Medicare has a lot of power to set up shipping and payment policies. For example, Medicare promotes a prospective payment adaptation based on DRG, which prevents unscrupulous providers to set too high a price. Meanwhile, the Patient Protection and Affordable Care Act has provided Medicare a mandate to promote cost-containment across the health care system, for example, by promoting the creation of responsible care organizations or by replacing cost-for-service payments with bundled payments.
Funding costs and challenges
Over the long-term, Medicare faces significant financial challenges due to increased overall health care costs, increased registration as the population ages, and a decrease in the ratio of workers to registries. Medicare's total expenditure is projected to increase from $ 523 billion in 2010 to about $ 900 billion by 2020. From 2010 to 2030, Medicare registrations are projected to increase from 47 million to 79 million, and the ratio of workers to registries is expected to decrease from 3.7 to 2 , 4. However, the ratio of workers to pensioners has declined steadily for decades, and the social insurance system remains sustainable due to increased worker productivity. There is some evidence that increased productivity will keep pace with demographic trends in the near future.
The Congressional Budget Office (CBO) wrote in 2008 that "future growth in spending per beneficiary for Medicare and Medicaid - the federal government's primary health care program - will be the most important determinant of long-term trends in federal spending. reducing cost growth - which will be difficult, in part because of the complexity of health policy options - is ultimately a long-term national challenge in setting federal fiscal policy. "
Overall health care costs are projected in 2011 to increase by 5.8 percent annually from 2010 to 2020, in part due to increased utilization of medical services, higher prices for services, and new technologies. Health care costs are rising across the board, but insurance costs have risen dramatically for families and employers as well as the federal government. In fact, since 1970, the per capita cost of personal coverage has grown by about one percent faster each year than Medicare's per capita cost. Since the late 1990s, Medicare has done very well with private insurance companies. Over the next decade, Medicare's per capita spending is projected to grow at a rate of 2.5 percent annually, compared with 4.8 percent private insurance. However, most experts and policymakers agree that health care costs are critical to the country's fiscal outlook. Much of the debate about the future of Medicare revolves around whether per capita costs should be reduced by limiting payments to providers or by shifting more costs to Medicare registrants.
Indicators
Some steps serve as an indicator of Medicare's long-term financial status. This includes total Medicare spending as part of gross domestic product (GDP), solvency of Medicare HI trust funds, growth of Medicare per capita spending relative to inflation and GDP growth per capita; general fund revenues as part of total Medicare spending; and actuarial estimates of the powerless obligations over a 75-year period and the unlimited horizon (expected premium/tax income against expected costs). The main problem in all of these indicators is comparing any future projection against the current law vs. what the actuaries are expected to happen. For example, the current legislation provides that Part A payments to hospitals and skilled care facilities will be cut substantially after 2028 and that doctors will not get an increase after 2025. The actuary expects that legislation will change to keep this event from happening.
This measure, which examines Medicare spending in the context of the US economy as a whole, is expected to increase from 3.6 percent in 2010 to 6.2 percent by 2090 under current legislation and more than 9 percent below what is truly is expected by actuaries to occur (called "illustrative examples" in the Supervisory Report of the recent year).
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This measure only involves Part A. Trust funds are considered bankrupt when the available income plus the existing balance will not cover 100 percent of the projected annual cost. According to recent estimates by Medicare executives (2016), trust funds are expected to go bankrupt in 11 years (2028), where the available time of income will cover 87 percent of the projected annual cost. Since Medicare began, this solvency projection ranges from two to 28 years, with an average of 11.3 years.
Medicare growth in per capita spending relative to inflation and per capita GDP growth
The Independent Payment Advisory Board (IPAB), the Affordable Care Act or "ACA" created, will use this measure to determine whether to recommend to Congressional proposals to reduce
Source of the article : Wikipedia
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