The week 4 signature Diet Analysis assignment has been designed for you to analyze and assess your own diet using the US Dietary Guidelines for Americans.
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PPTS_CH181.pptxChapter 18 Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating providers.
The primary care physicians in a POS plan usually make referrals to other providers in the plan.
If the physician makes a referral out of the network, the plan pays all or most of the bill.
If the client refers him or herself to a provider outside the network the co-payment and deductibles would increase.
Private Health Insurance Continued
Preferred Provider Organizations (PPOs) are a combination of traditional fee-for-service and an HMO.
A PPO requires that the clients choose a primary care physician to monitor their healthcare.
If the client decides to choose a physician that is not part of the plan, the client will pay a larger portion of the bill.
If the client’s physician is not a part of the network, he or she will not be required to change physicians to join a PPO.
Government Health Insurance/ Public Insurance
Government health insurance includes plans funded by governments at the federal, state, or local level.
The federal agency Centers for Medicare and Medicaid Services (CMS) administers the programs.
The Medicare Program—Title XVIII of the Social Security Act is the designated health insurance for the aged and disabled.
Government Health Insurance/ Public Insurance Continued
Medicare consists of two parts:
Hospital Insurance (HI), also known as Part A
Supplementary Medical Insurance (SMI), known as Part B
Part C, sometimes known as the Medicare Advantage program, was established as the Medicare+Choice program.
Part D, a prescription drug benefit that became available in 2004
Government Health Insurance/ Public Insurance Continued
Part A Coverage is provided automatically and is free of premiums to persons age 65 or over who are eligible for Social Security or Railroad Retirement benefits.
Provided to insured workers with ESRD (and to insured workers’ spouses and children with ESRD), and ineligible aged and disabled beneficiaries who voluntarily paid a monthly premium for their coverage.
Government Health Insurance/ Public Insurance Continued
Part B Coverage covers physicians’ and surgeons’ services, chiropractors, podiatrists, dentists, and optometrists.
Covers services provided by Medicare-approved practitioners such as:
Dietitians
Certified registered nurse anesthetists, clinical psychologists
Clinical social workers (other than in a hospital)
Physician assistants, and nurse practitioners and clinical nurse specialists
Government Health Insurance/ Public Insurance Continued
Coverage Gaps include:
Medicare deductibles
Co-payments
Excess charges by doctors who do not accept Medicare assignments
Medical services and supplies that Medicare do not cover
Government Health Insurance/ Public Insurance Continued
Medigap provides extra protection beyond Medicare.
Medigap is a type of private insurance coverage that may be purchased by an individual enrolled in Medicare.
Part D provides subsidized access to prescription drug insurance coverage upon payment of a premium individuals entitled to Part A or Part B.
Government Health Insurance/ Public Insurance Continued
The Medicaid Program is the largest source of funding for medical and health-related services for poor people.
Within broad national guidelines each state must:
establish its own eligibility standards
determine the type, amount, duration, and scope of services
set the rate of payment for services
administer the program
Government Health Insurance/ Public Insurance Continued
Basis of Eligibility—individuals are usually eligible for Medicaid if they:
meet the requirements for the AFDC
are less than 6 years of age with family income at or below 133 percent
are pregnant women with family income below 133 percent of the FPL
are Supplemental Security Income (SSI) recipients, etc.
Government Health Insurance/ Public Insurance Continued
Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)—known as “welfare reform” bill.
Welfare reform repealed the open-ended federal entitlement program known as Aid to Families with Dependent Children (AFDC) and replaced it with Temporary Assistance for Needy Families (TANF).
TANF limits a family’s lifetime cash welfare benefits to a maximum of 5 years.
Government Health Insurance/ Public Insurance Continued
State Children’s Health Insurance Program (SCHIP) covers individuals who have incomes too high to qualify for state medical assistance but cannot obtain private insurance.
Those who can qualify are:
children in low-income families
eligible children under the age of 19 whose state provides 12 months of continuous Medicaid coverage
Government Health Insurance/ Public Insurance Continued
Medicaid, Title XIX of the Social Security Act offers medical assistance for certain basic services to most categorically needy populations.
Box 5-1 presents services generally provided by the state Medicaid programs.
Government Health Insurance/ Public Insurance Continued
Balanced Budget Act includes a state option known as Programs of All-inclusive Care for the Elderly (PACE).
The PACE team offers and manages all health, medical, and social services.
Successful Community Strategies
The Illinois Department of Human Services integrated WIC with two state-funded programs:
Family Case Management (FCM) and Targeted Intensive Prenatal Case Management (TIPCM)
Integration of these programs allowed them to operate more efficiently.
For example, staff members of many local health departments were trained to provide both WIC and FCM services.
Topics for Discussion
How does poverty limit access to healthcare?
What is the difference between Aid to Families with Dependent Children (AFDC) and Temporary Assistance for Needy Families (TANF)?
Who does SCHIP cover?
What is the difference between Medicare and Medicaid?
