BHS 427 - Health Care Finance (Module 4-SLP) - Essay Example

Medicare Funding and Reimbursement People aged 65 or above, people below 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) are insured under Medicare Health Insurance. There are mainly two parts for the Medicare – Part A (Hospital Insurance) and Part B (Medical Insurance).Part A: Medicare hospital insurance is mainly for inpatient care in the hospitals when a patient is hospitalized. After discharge, skilled nursing facilities are provided.

The term is for short period and some conditions must be satisfied to be eligible for getting insured. If the husband or wife has paid Medicare taxes when employed, such people are enrolled to Part A without paying monthly premium. If Medicare taxes have not been paid during employment, they can apply for Part A and pay premium which changes year by year. The premium rate for 2009 is as follows:1. If the individual has 40 or more quarters of Medicare covered employment, then the premium is nil. 2. If the employment has 30-39 quarters Medicare coverage, then the premium is $244 per month.3. If the employment has less than 30 quarters of Medicare coverage, then the premium is $443For each benefit period the following is paid to the patient:A total of $1,068 for hospital stays of 1-60 days.

$267 per day for days 61-90 of hospital stay.$534 per day for days 91-150 of hospital stay (Lifetime Reserve Days).All costs for each day beyond 150 days” (What are the Medicare premiums and coinsurance rate for 2009?, 2008). $133.50 per day for days 21 through 100 each benefit period is paid as Skilled Nursing Facility Coinsurance:Part B: Medicare medical insurance is taken mainly to avail those services which Part A does not cover and it is optional. It offers the rights like doctors’ services, outpatient care and other medical services.

The premium is decided by the individual. Some pay a standard monthly premium of $96.40 and others on the basis of their income.Part D: It is the drug coverage insurance plan. Those who have Medicare can access prescription drug coverage irrespective of the income, health status etc.A case if costs more than the “fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for outliers).” (Outlier payments, 2006). Medicare payments to hospitals fall under two categories-prospective payment and physician payment.

The prospective payments include costs like operating cost, capital cost and outlier cost. Operating cost is paid if the patient has to stay long in the hospital. Capital cost includes cost for treatment and care to the patient. If a patient uses extraordinary resources then outlier cost is charged which is an additional payment. Physician payment is calculated on the basis of current procedural terminology (CPT) codes. The payment rate depends upon the Work RVU, Practise expense RVU and Malpractice RVU which may vary by region.

There are mainly two types of cases under the payment rules of Medicare:1. In case of Participating Physicians, 100% fee is approved by the Medicare. An individual has to pay only 20% of the cost; rest 80% is paid by the Medicare. 2. In case of Non Participating Physicians, only 95% of fee is approved. Out of this 80% is paid by Medicare and patient pays balance 20%3. In case of limiting charge, the patient has to pay the entire amount and Medicare reimburses 80% to the patient.In case Medicare does not pay the amount, individual can file an appeal within 120 days.

The individual has the right to file a fast appeal if the service is going to end soon. ReferencesOutlier payments: Background. (2006). CMS: Centers for Medicare & Medicaid Services. Retrieved June 5, 2009, from http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp#TopOfPageWhat are the Medicare premiums and coinsurance rate for 2009?: Answer: For each benefit period you pay. (2008). U S Department of health & human services. Retrieved June 5, 2009, from http://www.hhs.gov/faq/medicaremedicaid/650.html