The Center for Medicare and Medicaid Services (CMS) is a branch of the United States Department of Health and Human Services, formerly known as Health Care Financing Administration (HCFA). During the 1950s and 1960s government programs began to cover health care costs. On July 30, 1965, The Medicaid and Medicare programs signed into law as part of the Social Security Amendments of 1965, by Lyndon B. Johnson. The ceremony was held at Harry S. Truman Presidential Library in Independence, Missouri (U.S. Department of Health and Human Services, 2011). Since 1965, a number of changes have been made to CMS programs leading us to our current Medicaid and Medicare programs we have today.
Many seniors retire at the age of 65 by choice, others are forced to retire because of health issues, and some cannot afford to discontinue work because that would force them to choose between basic necessities and possibly life or death health care. According to CMS Chronic Condition Data Warehouse (CCW) Medicare Beneficiary Counts for 2000 through 2009, beneficiary demographics showed an aging population utilizing CMS. The national average of beneficiaries in 2006 was 2,079,437 and had grown to 2,448,689 by 2009 (CMS: Chronic Condition Data Warehouse (CCW), 2001).
Medicaid is an assistance program that began January 1, 1966. At that time only eight million people were eligible. Because of the overwhelming success of the program, in 2007, it provided health insurance for approximately 47 million Americans (U.S. Department of Health and Human Services ). Medicaid is a state administered program run by state and local governments within federal guidelines with each state setting its own guidelines regarding eligibility and services. Medicaid insures people of every age assuming that they meet specific criteria outlined by the program administrators (Centers for Medicare & Medicaid Services, 2011). There are two major groups with a major distinction between the two; they are the categorically needy (individuals who meet a specific criteria of mandatory Medicaid eligibility established by the federal government) and medically needy (allowing provision of Medicaid to certain groups of individuals who would not otherwise be eligible for Medicaid).
Medicaid serves low-income people of every age with limited income and resources. It covers individuals such as parents and children receiving Aid to Families with Dependent Children; pregnant women, children and teenagers under the age 18 (many states insure young adults until the age of 21); the blind receiving Aid to the Blind; the disabled receiving Aid to the Permanently and Totally Disabled; and individuals 65 or older (Medicaid, 2011). Medical bills are paid from federal, state, and local tax funds. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Disadvantages to Medicaid are the low reimbursement rate and is always the “payer of last resort” that is causing some physicians and caregivers to stop accepting Medicaid patients, resulting in a longer wait for care or travel to find accepting providers. Physicians have a choice if they will participate with Medicaid and Medicare.
Medicare is an insurance program that began July 1, 1966. 11 months after the enactment, 19 million elderly had already enrolled. Medical bills are paid from trust funds which those covered have paid into (Centers for Medicare & Medicaid Services, 2011). Primarily, it serves people older than 65, regardless of income; serves younger disabled people and dialysis patients; End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare is also a federal program. It is basically the same everywhere in the United States and is run by CMS. Medicare has major components, Part A (Hospital Insurance), Part B (Provider Coverage), Part C (Medicare Advantage), and Part D (Prescription Drug). Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums may be required for non-hospital coverage. Most people do not have to pay a premium for Part A. Part B is completely voluntary; everyone must pay something if they elect to receive the benefits as of January 1, 2007. Monthly premium are deducted from Social Security, Railroad Retirement, or Civil Service Retirement checks. If you do not receive any of these payments, Medicare sends you a bill for your Part B premium every three months (Medicare, 2011).
Medicare Part A. You are eligible for Part A at age 65 without having to pay premiums under certain conditions. Eligibility for premium-free Part A is also available if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. This is because they or a spouse paid Medicare taxes during the time they were working. If you (or your spouse) didn’t pay Medicare taxes while you worked and you are age 65 or older, you may buy Part A to assist in covering inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits (Malone, 2009).
Medicare Part B. This plan is optional. Part B helps pay for covered medical services and items when they are medically necessary. It helps cover medical services like doctors’ services, tests, outpatient care, home health services, durable medical equipment, and other medical services that Part A does not cover. Part B also covers some preventive services like examinations, lab tests, and screening shots to help prevent, find, or manage a medical problem (Malone, 2009).
Medicare Part C. A Medicare Advantage (MA) Plan is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, formerly known as Medicare + Choice, sometimes called “Part C” or “MA Plans,” are provided by private companies approved by Medicare and replaces Parts A, B, and D. The benefits to MA Plans may offer extra coverage, such as vision, hearing, dental, and health and wellness programs, for a lower cost than Medicare. In contrast, the choice of providers is limited (similar to Health Maintenance Organizations or PPO). Medicare pays a fixed amount for your care every month to the companies offering MA Plans. These companies must follow rules set by Medicare. However, each MA Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for nonemergency or non-urgent care). These rules can change each year (Malone, 2009).
Medicare Part D. The newest Medicare coverage plan since January 1, 2006 is the Medicare Part D Plan. These are prescription plans provided by private insurance companies.
In conclusion, I researched this topic for many reasons. First, for my professional knowledge; this will be valuable information for when I get into the health care field. With this information, I can assist other patients with information as it applies to billing and services available. It is vital to know how to use and access CMS information. As a future health care manager, I must meet the billing criteria of CMS. Otherwise, services and funding may be denied, delayed and cost the business money. Knowledge of the systems in place and attention to detail in the processes put in place could prevent mistakes potentially costing the company several thousand dollars and possible jail time. Penalties for fraud intended or not are severe and outlined in state and federal guidelines. Attention to detail is paramount because even an honest mistake can be considered as fraud and punishable as such.
Centers for Medicare & Medicaid Services. (2011, 5 13). Retrieved August 29, 2011, from CMS/Centers for Medicare & Medicaid Services: https://www.cms.gov CMS: Chronic Condition Data Warehouse (CCW). (2001, May 5). Summary Statistics. Retrieved August 29, 2011, from Chronic Condition Data Warehouse: http://www.ccwdata.org/cs/groups/public/documents/document/wls_ucm1-000772.pdf Malone, C. (2009). Administrative Medical Assisting: foundations and practices. Upper Saddle River, NJ: Prentice Hall. Medicaid. (2011).