Medicare
Medicare is a government national insurance program that provides health
insurance to American citizens aged 65 and older'' (Nowicki, 2018 p. 121). Medicare
insures seniors, disabled individuals eligible for social security and for a limited time end
stage renal patients. Medicare has four components: part A covers inpatient and home
health services, part B covers outpatient services, part C is Medicare Advantage, (this plan
offers HMO’s, PPO’s and covers medications) and part D which offers prescription
coverage.
A benefit of Medicare part A is the patient can see their preferred provider whereas
with part C patients need to remain in the Network. One challenge I found when
researching these programs was navigating part B - what services are covered.
Additionally, part D prescription drug coverage can be confusing as not all prescriptions
are covered or in some cases only the generic option is covered.
Whichever service you choose, make sure to do it three months before you turn 65
until three months after. This is considered the initial enrollment period and if you sign up
outside of this window you will be penalized and your premiums will be higher.
Medicaid
Medicaid (MassHealth) provides insurance to the medically indigent - individuals
who are able to pay normal living expenses but little more - they can not afford healthcare
expenses. (Nowicki, 2018, p 151). Where Medicare is age driven, Medicaid is a financial
driven assistance. This is the challenge of Medicaid - since it is financially driven, if your
income rises beyond 133% of the federal poverty level regardless of age, family status or
health you are no longer eligible for coverage (Melillo, 2021). On the facility side
Medicaid has lower reimbursements and can not be charged for missed appointments
therefore practices that have a large Medicaid patient base are generally less profitable.
HIPAA
The Health Insurance Portability and Accountability Act protects “currently
insured people from losing their coverage due to job change or family illness” (Nowicki,
2018, p.133). This is beneficial to the employee - no loss of coverage in between jobs.
HIPAA compliance at a corporate level can improve efficiency and reduce costs by
standardizing the electronic transmission of administrative and financial transactions.
There are challenges associated with HIPAA - bringing the facilities up to date with
privacy and cyber securities. Failure to comply with HIPAA regulations can cost $100-
250,000 per violation (with an annual cap at $1.5 million) and/or a 1-10 year prison
sentence (Vanderpool, 2019).
References
Melillo, G. (2021) Experts Outline Medicaid Challenges, Potential Reforms. AJMC
https://www.ajmc.com/view/obesity-various-other-conditions-more-likely-in-patients-
with-hs
Nowicki, M. (2018). Introduction To the financial management of healthcare
organizations. HAP/AUPHA< Health Administration Press.
Vanderpool D. (2019). HIPAA COMPLIANCE: A Common-Sense Approach. Innovations
in clinical neuroscience, 16(1-2), 38–41.
