Medicare services covered

Since 1983, Medicare has paid hospitals a fixed amount per admission for a package of services based on a patient s primary diagnosis and major treatments. Medicare will now cover attendant hospital costs for patients receiving an experimental drug if the admission was not solely for the experiment. Some observers have suggested that adjustments to hospital payments allowed by Medicare to cover costs associated with medical education also underwrite some of the patient and faculty costs associated with clinical research. Medicare contractors, the companies that administer the Medicare program under contract with HCFA, interpret these policies differently in different parts of the country (395). 

Congress creates Medicare, a public health insurance program for elderly persons that covers hospital stays and clinical services but not prescription drugs. 

Medicare Advantage A Medicare-approved private health care plan, such as a health maintenance network or preferred provider organization, that serves as an alternative to a fee-for-service plan for Medicare participants and partially or totally covers prescription drug costs. 

Figure 16-1. U.S. Prescription Drug Expenditures by Source of Payment, 1990-2005. Source Data were obtained from the Centers for Medicare and Madicaid Service at http //www.cms.hhs.gov/NationalHealthExpendData/ Note PT OOP is direct spending by consumers for prescriptions drugs. It includes prescriptions not covered by a third party and patient cost-sharing for third parly prescriptions.

U.S. Department of Health and Human Services (DHHS). 2003a. Covered Entity Decision Tools, Centers for Medicare and Medicaid Services, modified July 24, 2003 available at www.cms.hhs.gov/hipaa/hipaa2/ support/tools/decisionsupport/default.asp. 

The U.S. is unique among advanced nations in that it has resisted the implementation of a system of imiversal health care and instead has gradually built a system in which employers are the primary sponsors of health care coverage for the majority of the population. Medicare and Medicaid cover the elderly, disabled, and very poor. According to data from the U.S. Census Bureau, a small proportion of people, less than 7% of the population under 65 years of age, purchase health insurance on their own. In 2002, the remaining 41 million persons were uninsured. The uninsured represent 14.6% of the total population, 16.5% of the population under 65 years. Those with adequate resources pay out of their pockets for health care. The others go without care, delay care, or seek health services from a fragile and incomplete system of charity care and safety-net providers. 

Medicare Part B is a voluntary form of insurance, and beneficiaries choose whether to enroll in this part of Medicare. Parf B is financed parfly by a premium charged to the beneficiary ( 54/mo in 2002) and fypically is deducted from the beneficiary s Social Security check. The rest of Parf B funding comes from general federal fax revenues. Medicare Parf B helps cover physicians services, outpatienf hospifal care, and some ofher medical services not covered under Part A. Nearly 95% of Medicare beneficiaries choose to enroll in Part B because the federal government pays for 75% of the premium cost. Medicaid pays the Part B premium for low-income elderly. 

Historically, a lack of public insurance programs created obstacles to health care services. For those who could not afford to pay for private insurance, the costs associated with health care were larger than most could afford. After lengthy debate, the U.S. Congress passed legislation in 1965 that established Medicare and Medicaid. Medicare covers over 95% of the elderly in the United States as well as many individuals who are disabled. Coverage for the disabled began in 1973 and is divided in two parts 1) hospital insurance and 2) supplementary medical insurance. The total disbursement for Medicare in 1997 was 213,575 billion, and there were 36,460,143 enrollees, of which 32,164,416 were elderly. 

The program covers children under six years whose family income is no more than 133% of the federal poverty level definition, pregnant women up to 133% of the poverty level, some Medicare beneficiaries, and recipients of adoption assistance and foster care programs. Medicaid covers virtually all outpatient and inpatient health and rehabilitative services, home health, long-term care, dental, prosthetic, pharmacy, and optical services and goods. Pharmacy benefit rules state ... 

By law, Medicare does not cover any drugs administered outside of the hospital or a physician s office, and the program does not pay for clinical research (487). Furthermore, to be covered by Medicare, drugs must be reasonable and necessary, a criterion that the Health Care Financing Administration (HCFA) has interpreted. .. to exclude. .. those medical and health care services that are not demonstrated to be safe and effective by clinical evidence (487). HCFA has taken this to mean that experimental and investigational drugs are not covered. 

Health Care Financing Administration (under the Department of Health and Human Services) for administration of specific Medicare tasks. These tasks include determiningg reasonable costs for covered items and services, making payments, and guarding against unnecessary use of covered services. 

Medicare A Federally administered health insurance program covering the cost of services for people 65 years of age or older, receiving Social Security Disability Insurance payments for at least two years, or with end-stage renal disease. Medicare consists of two separate but coordinated programs-hospital insurance (Part A) and supplementary medical insurance (Part B). Health insurance protection is available to insured persons without regard to income. 

Medicare a nationwide, federally-administered health insurance program which covers the costs of hospitalization, medical care, and some related services for eligible persons. Medicare has two parts Part A covers inpatient costs. Medicare pays for pharmaceuticals provided in hospitals, but not for those provided in outpatient settings. Also called Supplementary Medical Insurance Program. Part B covers outpatient costs for Medicare patients. 

Medicare supplement policy a policy guaranteeing that a health plan will pay a policyholder s coinsurance, deductible and copayments and will provide additional health plan or non-Medicare coverage for services up to a predefined benefit limit. In essence, the product pays for the portion of the cost of services not covered by Medicare. Also called Medigap or Medicare wrap. 

Medicare Part A which provides hospitalization insurance that covers inpatient hospital, home health, skilled nursing facility, psychiatric hospital, and hospice care services. 

Medicare Part B which provides medical insurance for physician s services, outpatient services, some mental health services, durable medical equipment, some preventive services, and home health visits not covered under Part A. 

MDCR MarketScan Medicare Supplemental Beneficiaries Captures administrative daims for retirees with Medicare supplemental insurance paid by employers, induding services provided under Medicare-covered pa)mient, employer-paid portion, and any out-of-pocket e> enses Total 4.6 m % male 44% Mean age 73.5 (8.0) Pt-years 13.4 m 2003-2009... 

The Centers for Medicare Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the United States through the Clinical Laboratory Improvement Amendments (CLIA). In total, CLIA covers approximately 200,000 laboratory entities. The... 

Medicare does not provide for custodial services (35) so that few LTMV patients covered by Medicare are able to return home. Some private insurers are more generous, providing 8 to 12 hours of skilled nursing care per day. Even then, the family has to assume a large share of the caregiving and financial burden so that management at home is still difficult. 

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