a There is an enormous amount of information regarding Medicare, Medicaid, and HIPAA.
There are several benefits as well as challenges with these third party payers as well as
HIPAA. Medicare initially had two parts, part A and part B. Part A was aimed at hospital
and inpatient care, part B was for outpatient and physician care. In 1997 part C was
introduced and became known as Medicare advantage which combines parts A and B into
a managed care program. Part D came about in 2003 and included prescription coverage
(Nowicki, 2022).
a a a A benefit of Medicare is it allows for older, ESRD, and ALS patients as well as
younger social security disability patients to receive medical coverage. This population of
patients are likely the sickest and who need the coverage and medical care. A challenge is
the massive price tag that comes with it. Recent Medicare spending’s as of 2019 were
upward of several hundred billion dollars. 43% of Medicare is financed through general
revenue, and has been projected to be bankrupt by 2026. Healthcare cost control through
proper rules and regulations would help to offset the under projected costs of the program
(Cubanski & Neuman, 2021).
a a a Medicaid is a program signed to law in 1965 as part of the social security
amendments. This program provides health insurance to individuals who can not afford to
buy insurance for themselves or their family. This is financed through federal and state
government. A benefit of Medicaid which was an expansion, is the Children's Health
Insurance Program or (CHIP). This program ensures medical coverage for children in
families that do not qualify for Medicaid but can not afford private insurance. It is funded
by both state and federal government as well. This ensures medical and dental coverage
for children across the country (GoMoHealth, 2021).
a a a A challenge of Medicaid is that it can lead to fragmented care and decreased
patient engagement. Because each state has its own criteria and requirements, patients may
have less understanding of eligibility, specifically minorities, non-English speaking, and
people with decreased health literacy. Making enrollment and eligibility requirements
easier to understand is critical to help more individuals (GoMoHealth, 2021).
a a a The aforementioned entities are all covered under HIPAA. They are responsible
for compliance and must meet privacy standards as is with all private insurance
companies. HIPAA continues to protect patient private health information (PHI) and can
have a major impact on fraud and abuse, ultimately decreasing the immense financial bill
attached to these programs (Centers for Medicare and Medicaid Services, 2022).
Centers for Medicare and Medicaid Services (2022). HIPAA statutes and regulations.
[Retrieved from] https://www.cms.gov
Cubanski, J., & Neuman, T., (2021). Faq’s on medicare financing and trust fund solvency.
[Retrieved from] https://www.kff.org
GoMoHealth (2021). Top 3 challenges for Medicaid patients in care accessibility &
provider engagement. [Retrieved from] https://gomohealth.com
Nowicki, M., (2022). Introduction to the Financial Management of Healthcare
Organizations, Eighth Edition: Vol. Eighth edition. Gateway to Healthcare
Management.
