Question

what is the role of medicare and medicaid service's in health? and how would you improve medicare?

Answer 1

Medicaid is the joint federal and state program designed to provide health care coverage as a free of or low cost to millions of Americans, especially to the underserved and people who need special care. The main beneficiaries of Medicaid are low-income people, families and children, pregnant women, the elderly, and people with disabilities. The funding for Medicaid is provided jointly by the federal and state government. The guidelines for the program are designed by the federal government. The Medicaid programs have slight differences from state to state. Medicaid especially concentrates on certain categories of people who have low income and few assets, other than the home they live in. The people over 65 and those with disabilities are also covered by Medicaid programme depending on their income. The Medicaid program also covers some health care services that Medicare doesn't cover. The services like Medicare premiums, deductibles, and co-payments for people who are enrolled in both Medicare and Medicaid programs are also paid by Medicaid. Other services funded by Medicaid are long-term nursing home care, long-term, assisted living and in-home personal care.

Medicaid and Medicare are two entirely different programs. An individual can be eligible for both Medicaid and Medicare. Medicare covers everyone ages 65 or older, and people with long-term disability, irrespective of their income or assets. Medicaid is designed for low-income people and those with very few assets other than a home. Medicaid program covers even the services not covered by Medicare. Medicare may leave the medical expenses like Medicare premiums, deductibles, and co-payments, and the cost of some prescription drugs not covered by a Medicare Part D prescription drug plan. Medicaid will pay the additional amount for the beneficiary who's enrolled in both programs.

The income determination for Medicaid coverage is determined by the state where you live. The person will also be eligible for Medicaid medical coverage if his/her income falls below the eligibility standard for the federal Government's Supplemental Security Income program (SSI). Medicaid accounts the income of both spouses if either spouse in a married couple applies for Medicaid if they are living together. The benefits like free housing and regular meals from family or friends, the bills regularly paid for them are also considered as income while assessing Medicaid eligibility.

Medicaid covers a special category of people known as “medically needy” whose income is higher than the state's Medicaid eligibility level if they also have regular medical expenses that aren't paid by another program or insurance.

Medicare is the federal health insurance program designed for :

• People who are 65 years or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

Medicare has different parts to help cover specific services.

Medicare Part A (Hospital Insurance)

The Part A of Medicare covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)  

The Part B of Medicare covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Medicare Part D (prescription drug coverage)

The Part D of Medicare adds prescription drug coverage to:

• Original Medicare
• Some Medicare Cost Plans
• Some Medicare Private-Fee-for-Service Plans
• Medicare Medical Savings Account Plans

The above three plans are offered by insurance companies and other private companies approved by Medicare. There are Medicare Advantage Plans, that may also offer prescription drug coverage and follows the same rules as Medicare Prescription Drug Plans. The Part C or) is an alternative to Original Medicare. This is a “bundled” plan and includes Part A, Part B, and usually Part D of Medicare.

Who is eligible for Medicaid?

• The mandatory eligibility groups
• Low-Income Families
• Transitional Medical Assistance
• Extended Medicaid due to Child or Spousal Support Collections
• Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care
• Qualified Pregnant Women and Children
• Mandatory Poverty Level Related Pregnant Women
• Mandatory Poverty Level Related Infants
• Mandatory Poverty Level Related Children Aged 1-5
• Mandatory Poverty Level Related Children Aged 6-18
• Deemed Newborns
• Individuals Receiving SSI
• Aged, Blind and Disabled Individuals in 209(b) States
• Individuals Receiving Mandatory State Supplements
• Individuals Who Are Essential Spouses
• Institutionalized Individuals Continuously Eligible Since 1973
• Blind or Disabled Individuals Eligible in 1973
• Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972

Who is eligible for Medicare?

Medicare is a health insurance policy offered to the senior-citizen set, people under 65 who are disabled in certain ways are also included in this program. It is not an income-based support. The paid Medicare taxes from the earnings one will make you automatically eligible for Medicare at age 65.

One may qualify for Medicare due to a disability if he/she has been receiving SSDI checks for more than 24 months, also known as the two-year waiting period. One will automatically be enrolled in Medicare at the beginning of the 25th month in this situation. While receiving SSDI because of Amyotrophic Lateral Sclerosis(ALS), Medicare automatically begins the first month along with the starting of SSDI benefits.

• People with End-Stage Renal Disease (ESRD) or kidney failure will be eligible for Medicare even if under.
• People will qualify for Medicare if diagnosed with ESRD and are undergoing dialysis treatments or have had a kidney transplant.
• People who are eligible to receive Railroad Retirement benefits.
• The individual, a spouse, or a parent have paid Medicare taxes for the required period of time as specified by the Social Security Administration.

Financing

Medicaid program is jointly funded by the federal government and states. The Federal Medical Assistance Percentage (FMAP) will be provided by states as a specific percentage of program expenditures. The States make sure that they can provide their part of Medicaid expenses for the care and services available under their plan.The Medicaid provider payment rates can be regulated by the States by their own within federal requirements. It is generally paid by fee-for-service or managed care arrangements.

Medicare funding primarily comes from Social Security Administration like general revenues, payroll tax revenues, and premiums paid by beneficiaries. Other sources of income for Medicare include taxes on Social Security benefits, payments from states and its interest. All taxpayers pay 1.45% of the earnings into Federal Insurance Contributions Act and employers pay another 1.45% which makes a total of 2.9%.

The Medicare serves older people, 65 years and over and some people under the age of 65 who have a qualifying disability or other medical condition. The older adults would find themselves in a challenging situation without Medicare. The reasons are :

-increased demand for health insurance because they are ageing and are retired and no longer have an employer-sponsored insurance plan

- the private insurance can be difficult to afford when living off of Social Security and other limited retirement funds.

Most of the beneficiaries of Medicare receive “premium-free” Part A of Medicare, in which they do not have to pay any monthly or yearly premiums. These health care costs in the form of copays, coinsurance and deductibles and some of which can be covered by a Medicare Supplement Insurance plan. The optional Part B of Medicare is obtained with an average monthly premium of just $109 and offers patients an extensive range of coverage.

Considering the cost of private insurance generally increases with age, Medicare provides a viable solution for the senior population to obtain the health care they need.

Improvement plans:

The Medicare program possesses a proven track record in preserving quality and generating customer satisfaction. If it can cover all Americans, selection bias like the insurer’s preference to cover healthier, more profitable people and shun the sicker and more expensive can be eliminated. If the Centers for Medicare and Medicaid Services (CMS) would accelerate value-based payments to providers and cost shifting from Medicare-covered populations to populations covered by employer-sponsored commercial insurance plans would be eliminated and the health care costs would be managed efficiently.

The opponents of Medicare Advantage emphasizes that it may reduce patient choices. The involvement of the wide network of health care services in Medicare will support the rapid growth and the high consumer satisfaction. CMS should plan incentives into the present Medicare Advantage plans for beneficiaries to make good personal choices to improve the patient satisfaction. The approximate number of uninsured people is 50 million in the US and it is drastically rising commercial premiums for the rest of the people. This can be eliminated by the proper modification of the Medicare.

The improvement in Medicare can be made by:

-         Design a more flexible programme, strengthening Medicare Advantage, provide adequate funding and must be predictable and consistent.

-         Improve the health outcomes by providing the Medicare beneficiaries with a value-based care.

-         Accelerate the best practices of value-based payments, data analytics, health care coordination and enforce the consumer engagement to improve outcomes.

-         Ensure the involvement of all beneficiaries in healthy decision-making.

-         Improve the consumer experience by use of consumer-friendly tools and flexible incentive programs,

-         Develop the Original Medicare's Existing Infrastructure to Ensure the Sustainability of the Medicare Program.

-         Allow the timely, consumer-friendly access to comparisons of clinical quality and price