Wednesday, July 17, 2024

Is Medicare A Federal Program

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How Effective Is Medicaid

Medicare and the FEHB Program

Medicaid is very effective in providing health insurance coverage to the most vulnerable. Since the ACAs major coverage expansions took effect in 2014, Medicaid has helped to reduce the number of uninsured from 45 million to 29 million. If Medicaid did not exist, most of the tens of millions of Medicaid enrollees would be uninsured. This is because private health insurance is generally not an option for Medicaid beneficiaries: many low-income workers do not have access to coverage for themselves and their families through their jobs and cannot afford to purchase coverage in the individual market. The creation of Medicaid, subsequent expansions of Medicaid coverage to children and pregnant women in the 1980s and 1990s, and the most recent expansion of Medicaid coverage to low-income adults under the ACA all have led to significant drops in the share of Americans without health insurance coverage.

Medicaid is also effective in improving access to care, in supporting financial stability among low-income families, and in improving health outcomes. Some of the clearest evidence comes from the ACA expansion of Medicaid coverage to low-income adults, which provides a recent natural experiment, letting researchers compare outcomes in states that did and did not adopt the expansion.

Who Is Eligible For Medicaid

Medicaid is an entitlement program, which means that anyone who meets eligibility rules has a right to enroll in Medicaid coverage. It also means that states have guaranteed federal financial support for part of the cost of their Medicaid programs.

In order to receive federal funding, states must cover certain mandatory populations:

  • children through age 18 in families with income below 138 percent of the federal poverty line
  • people who are pregnant and have income below 138 percent of the poverty line
  • certain parents or caretakers with very low income and
  • most seniors and people with disabilities who receive cash assistance through the Supplemental Security Income program.

States may also receive federal Medicaid funds to cover optional populations. These include: people in the groups listed above whose income exceeds the limits for mandatory coverage seniors and people with disabilities not receiving SSI and with income below the poverty line medically needy people and other people with higher income who need long-term services and supports and thanks to the Affordable Care Act non-disabled adults with income below 138 percent of the poverty line, including those without children. The ACA was intended to extend coverage to all such adults, but a 2012 Supreme Court decision gave states the choice of whether to expand their programs.

States Give Requirements For Medigap Variety

Although Medicare is a federal program, states help regulate Medigap by licensing companies that offer Medigap insurance companies. In other words, states require that private insurance carriers offer a wide variety of Medigap insurance options.

Law standardizes each type of Medigap policy to cover specific Medicare-approved services in specific amounts, meaning that all Medigap plans of the same type only differ in terms of premium charged by the private carrier.

States mandate the availability of different Medigap options to account for wide medical needs and cost preferences, regardless of a persons location.

The private companies that offer Medicare Supplements must offer an approved combination of plans. States require a combination of comprehensive plans along with any limited option plans.

Despite being subject to state rules for types of Medigap plans, the insurance companies offering the policies can assess a persons medical history to determine whether to accept or reject applications.

Medicare Supplement requires Medicare Parts A, and B. Acceptance is guaranteed during open enrollments and the initial enrollment period.

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Delivering Health Care Services To Specific Groups

We provide certain direct health care services to some population groups, including:

  • First Nations people living on reserves
  • Inuit
  • serving members of the Canadian Forces
  • eligible veterans
  • tax rebates to public institutions for health services
  • deductions for private health insurance premiums for the self-employed

Federal Employee Health Benefits And Medicare

Medicare Proposes Massive Cuts to Reimbursement for ...
  • A Federal Employee Health Benefits plan and Medicare can be used together. But whether you enroll in Part A or Part B depends on your income, premiums, out-of-pocket costs and other considerations.

Government programs, by themselves, can be complicated. Combine two federal government programs, and you can have even more challenges to understanding all of the benefits, requirements, costs and more.

Heres a perfect example: Some retired federal government employees qualify for insurance called the Federal Employee Health Benefits program . Once they reach age 65, the typically also qualify for Medicare.

Which program should they use? Do they need to enroll in Medicare if they already have FEHB benefits?

You guessed it its complicated.

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What Type Of Expenses Are Covered By Medicare

Medicare has four parts or programs which are:

Medicare Part A

Medicare Part A helps pay for: inpatient hospital care critical access hospitals skilled nursing facility care some home health care and hospice care. Most enrollees do not pay a monthly premium because they have prepaid the premiums through the Medicare Part A payroll tax.

Medicare Part B

Medicare Part B helps pay for: doctors services ambulance services outpatient hospital care x-rays and laboratory tests durable medical equipment and supplies certain preventative care other outpatient services and some other medical services Part A does not cover, such as physical and occupational therapy. Enrollees pay a monthly premium, usually deducted from their monthly Social Security check.

Medicare Part C

An individual enrolled in a Medicare Advantage Plan generally gets all of his or her Medicare benefits, which may include prescription drugs, through one of the following types of plans: Medicare HMOs Medicare PPO plans Medicare Special Needs Plans Medicare Private Fee-for-Service Plans or Medicare Medical Savings Account Plans.

Medicare Part D

Under this program, private companies provide prescription drug coverage. Enrollees must pay a monthly premium, usually deducted from their monthly Social Security check.

What Are The Parts Of Medicare

The different parts of Medicare help cover specific services:

  • Medicare Part A Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
  • Medicare Part D Helps cover the cost of prescription drugs .

Read Also: When Do Medicare Benefits Kick In

Medicare Has Different Parts That Help Cover Specific Services:

Medicare Part A – Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities . It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.

Medicare Part B – Part B helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay a monthly premium for Part B.

Medicare Part D – Medicare prescription drug coverage is available to everyone with Medicare. To get Medicare prescription drug coverage, people must join a plan approved by Medicare that offers Medicare drug coverage. Most people pay a monthly premium for Part D.

If youre a person with Medicare or help a person with Medicare, visit to find more information about Medicare.

Program Financing Beneficiary Liabilities And Provider Payments

Medicare Parts A, C, D and FEHB

All financial operations for Medicare are handled through two trust funds, one for the HI program and one for the SMI program. These trust funds, which are special accounts in the U.S. Treasury, are credited with all receipts and charged with all expenditures for benefits and administrative costs. The trust funds cannot be used for any other purpose. Assets not needed for the payment of costs are invested in special Treasury securities. The following sections describe Medicare’s financing provisions, beneficiary cost-sharing requirements, and the basis for determining Medicare reimbursements to health care providers.

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What Is Medicare What Is Medicaid

Medicare is a federal program generally for people who are 65 or older or have a qualifying disability or medical condition. Medicare Part A and Part B are provided by the federal government, and Medicare Part C and Part D, while federally governed, are provided by private insurance companies.

Medicaid is a state government program that helps pay health care costs for people with limited income and resources, and different programs exist for specific populations. Medicaid plans vary from state-to-state but follow federal guidelines for benefits.

Does The Federal Government Control Health Care

The ACA established shared responsibility among government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health insurance. The U.S. Department of Health and Human Services is the federal governments principal agency involved with health care services.

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Can You Have Both Medicare And Medicaid

Yes, some people can have both Medicare and Medicaid. People who qualify for both Medicare and Medicaid are called dual eligible. If you qualify and choose to enroll in both programs, the two can work together to help cover most of your health care costs. You may also be eligible for a special kind of Medicare Advantage plan called a Dual Special Needs Plan. You can learn more about being dual eligible and how Medicare coverage can work for you here.

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ON SCREEN TEXT: Medicare Conversations Dual Special Needs Plans…

A question appears beside a yellow circle labeled DSNP.

ON SCREEN TEXT:What is a Dual Special Needs Plan ?

A woman with light brown hair sits in a white chair as she interviews.

A pile of books sits on an end table beside her.

ON SCREEN TEXT: Holly Martin, Dual Special Needs Expert

ON SCREEN TEXT: Medicare Made Clear® by UnitedHealthcare®

HOLLY: Hello, everyone. I’m Holly Martin and over the last several years, I have worked on bringing education and awareness to Dual Special Needs Plans.

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ON SCREEN TEXT: What they are Why they are different Who is eligible

So, let’s go ahead and get started.

A question appears beside two circles, one labeled Medicaid, the other labeled Medicare.

How Do You Decide Between Fehb Vs Medicare

Medicare and Medicaid: The Differences

David Levine is an award-winning writer and editor whose work has been featured in the New York Times, New York Daily News, Sports Illustrated, American Heritage, U.S. News & World Report and others.

David has covered health, health insurance and health policy topics among many others since 2017. He earned a Bachelor’s Degree in English from the University of Rochester and currently lives in Albany, New York.

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Who Pays For Medicaid

Medicaid does not pay money to individuals but sends payments directly to healthcare providers.

States make these payments according to a fee-for-service agreement or through prepayment arrangements, such as health maintenance organizations . The federal government then reimburse each state for a percentage share of their Medicaid expenditures.

This Federal Medical Assistance Percentage changes each year and depends on the states average per capita income level.

The reimbursement rate begins at 50% and reaches 77% in 2020. Wealthier states receive a smaller share than states with less money.

In the states that chose to expand their coverage under the Affordable Care Act, more adults and families on low incomes are eligible with the new provision allowing enrolment at up to 138% of the FPL. In return, the federal government cover all expansion costs for the first 3 years and over 90% of the costs moving forward.

Medicare is a federal health insurance program that funds hospital and medical care for older people in the U.S. Some people with disabilities also benefit from Medicare.

The program consists of:

  • Part A and Part B for hospital and medical insurance
  • Part C and Part D that provide flexibility and prescription drugs

Contact Your Local State Health Insurance Assistance Program

Based on the information you provided, you do not appear to be eligible for Medicare cost-saving programs.

Each state offers a State Health Insurance Assistance Program , partly funded by the federal government, to give you free counseling and assistance. A SHIP counselor may be available by phone or in person.

Visit to find your local SHIP office.

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Unitedhealthcare Senior Care Options Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Reimbursement For Part A Services


For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. In a prospective payment system, the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care. The actual allotment of funds is based on a list of diagnosis-related groups . The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare’s use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of “upcoding”, when a physician makes a more severe diagnosis to hedge against accidental costs.

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Contact A Knowledgeable Medicare Compliance Consultant At Oberheiden Pc Today

A compliance program will help your organization avoid inadvertent violations. However, it is common for even the most well-intentioned organization to inadvertently engage in conduct that may constitute Medicare fraud or abuse. In these situations, having a compliance program can show investigators that your organization takes compliance seriously and may assist in wrapping up an investigation without the government formally filing charges. However, if you are currently facing a Medicare audit or investigation and worry about your level of compliance, there may still be steps you can take to mitigate your risk. In these situations, it is especially important to reach out to an experienced Medicare compliance consultant at Oberheiden, P.C. to identify what you can do to lessen your risk exposure. To learn more, and to schedule a free consultation with a Medicare compliance consultant, give Oberheiden, P.C. a call at 1-888-680-1745. You can also connect with us through our online contact form and one of our Medicare compliance consultants will be in touch shortly.

Medicaid Vs Medicare: You Can Have Both

Posted: January 17, 2020

Medicaid and Medicare. Its hard to think of two words that cause as much confusion.

  • Whats the difference between these two government health insurance programs?
  • What exactly are Medicaid and Medicare?
  • Whos eligible to get Medicaid or to get Medicare?
  • And how can some people get both?

Read on to find out the answers to these questions and more.

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Proposals For Reforming Medicare

As legislators continue to seek new ways to control the cost of Medicare, a number of new proposals to reform Medicare have been introduced in recent years.

Premium support

Since the mid-1990s, there have been a number of proposals to change Medicare from a publicly run social insurance program with a defined benefit, for which there is no limit to the government’s expenses, into a publicly run health plan program that offers “premium support” for enrollees. The basic concept behind the proposals is that the government would make a defined contribution, that is a premium support, to the health plan of a Medicare enrollee’s choice. Sponsors would compete to provide Medicare benefits and this competition would set the level of fixed contribution. Additionally, enrollees would be able to purchase greater coverage by paying more in addition to the fixed government contribution. Conversely, enrollees could choose lower cost coverage and keep the difference between their coverage costs and the fixed government contribution. The goal of premium Medicare plans is for greater cost-effectiveness if such a proposal worked as planned, the financial incentive would be greatest for Medicare plans that offer the best care at the lowest cost.

Currently, public Part C Medicare health plans avoid this issue with an indexed risk formula that provides lower per capita payments to sponsors for relatively healthy plan members and higher per capita payments for less healthy members.


Should You Enroll In Medicare Part A

Medicare and Medicaid

Most people qualify for premium-free Part A. So it may make sense to enroll in the coverage if you dont have to pay a monthly premium for it. Part A can be combined with FEHB coverage to help cover some of the out-of-pocket costs for such expenses as inpatient stays in a hospital or skilled nursing facility.

One drawback is that if you enroll in Part A, you cannot contribute to a Health Savings Account . You might consider delaying enrollment in Part A if your FEHB coverage qualifies you for an HSA and you want to continue making contributions to it.

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