HMGT 300

Type of insurance and primary payer/s

Type of HC service delivery structure

Regulated at what level?

Who are the consumers?

Type of provider business structure

Medicare

Medicare and Medicaid are U.S. government-sponsored programs designed to help cover healthcare costs for American citizens.

Medicare covers most medical services, including inpatient and outpatient care, physician services, diagnostic and preventive care and, since 2006, outpatient prescription drugs under Part D plans

Centers for Medicare & Medicaid Services 

Medicare is the federal health insurance program for: People who are 65 or older. Certain younger people with disabilities. \

Tax payer money, government contribution and federal budget distributions.

Medicaid

Medicare and Medicaid are U.S. government-sponsored programs designed to help cover healthcare costs for American citizens.

Hospitalization

Laboratory services

X-rays

Doctor services

Family planning

Nursing services

Nursing facility services

Home healthcare for people eligible for nursing facility services

Clinic treatment

Pediatric and family nurse practitioner services

Midwife services

Each state also has the option of including additional benefits, such as prescription drug coverage, optometrist services, eyeglasses

CMS also monitors Medicaid programs offered by each state.

 eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is directed by states, abiding by federal regulations. The program is funded jointly by states and the federal government, but the states have more say in allocation of funds and what they will include.

The Center for Medicaid and CHIP

Private Insurance

The three primary types of health insurance payers are: Commercial (Aetna, Cigna, United Healthcare, etc.) Private (Blue Cross Blue Shield) Government (Medicare, Medicaid, TRICARE, etc.)

 Private health – truly means out of pocket (the insured pays), and it’s customized to the payer, they choose what type of coverage or care they like.

It is regulated by the state governments, not by the federal government.

Employers can contribute to this by putting it in their benefits package.

health maintenance organization (HMO), an HMO point of service (HMO-POS) or a preferred provider organization (PPO).

TRICARE

TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. TRICARE offers eligible beneficiaries many choices for their health care.

TRICARE provides comprehensive coverage to all beneficiaries, including: Health plans. Special programs which includes TRICARE; Prime, Select, Extra, Standard, For Life, Young Adult, Reserve Select and Retired Reserve.

TRICARE is managed by the Defense Health Agency under leadership of the Assistant Secretary of Defense (Health Affairs)

Tricare is a health insurance program supports military members, their families, students, people with disabilities and retires, some survivors & former spouses. To use Tricare, you must be listed in DEERS as being eligible for military health care benefits.

TRICARE Prime or PRO

CHIP

The Children’s Health Insurance Program (CHIP) provides medical coverage for individuals under age 19 whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage. Congress passed CHIP in 1997 during the Clinton administration.

Federal law provides states with the option to cover targeted low-income children and targeted low-income pregnant women under a separate CHIP. In addition, states can provide coverage to certain groups that were historically excluded from CHIP, such as children or pregnant women that are lawfully residing, or have access to public employee coverage. Descriptions of these options are provided below.

Targeted Low-Income Children

In order to be eligible for CHIP, a child must be:

Under 19 years of age,

Uninsured (determined ineligible for Medicaid, and not covered through a group health plan or creditable health insurance),

A citizen or meet immigration requirements,

A resident of the state, and

Eligible within the state’s CHIP income range, based on family income, and any other state specified rules in the CHIP state plan

Department of Health and Human Services (HHS) The federal agency that oversees

CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP).

children

  The Children's Health Insurance Program (CHIP) is funded jointly by the federal government and states through a formula based on the Medicaid Federal Medical Assistance Percentage (FMAP)