Home Health Care Akron Ohio - Medicaid Certified Akron Ohio - Medicare Certified Akron Ohio - RN Nurse Akron Ohio -
LPN Nurse Akron Ohio - Social Services Akron Ohio - Rehabitative Services Akron Ohio - Personal Care Aides Akron Ohio -
Private Duty Care Akron Ohio - Visiting Nurse Akron Ohio - Nursing Care Akron Ohio - Home Health Care Akron Ohio -
Restorative Services Akron Ohio - Home Healthcare Aides Akron Ohio - Personal Care Attendants Akron Ohio -
Home Healthcare Akron Ohio - Healthcare Akron Ohio - HIPAA Akron Ohio
Home Health Care Perry Ohio - Medicaid Certified Perry Ohio - Medicare Certified Perry Ohio - RN Nurse Perry Ohio -
LPN Nurse Perry Ohio - Social Services Perry Ohio - Rehabitative Services Perry Ohio - Personal Care Aides Perry Ohio -
Private Duty Care Perry Ohio - Visiting Nurse Perry Ohio - Nursing Care Perry Ohio - Home Health Care Perry Ohio -
Restorative Services Perry Ohio - Home Healthcare Aides Perry Ohio - Personal Care Attendants Perry Ohio -
Home Healthcare Perry Ohio - Healthcare Perry Ohio - HIPAA Perry Ohio
Home Health Care Columbus Ohio - Medicaid Certified Columbus Ohio - Medicare Certified Columbus Ohio - RN Nurse Columbus Ohio -
LPN Nurse Columbus Ohio - Social Services Columbus Ohio - Rehabitative Services Columbus Ohio - Personal Care Aides Columbus Ohio -
Private Duty Care Columbus Ohio - Visiting Nurse Columbus Ohio - Nursing Care Columbus Ohio - Home Health Care Columbus Ohio -
Restorative Services Columbus Ohio - Home Healthcare Aides Columbus Ohio - Personal Care Attendants Columbus Ohio -
Home Healthcare Columbus Ohio - Healthcare Columbus Ohio - HIPAA Columbus Ohio
Medical Testing - Point-of-Care Medical Testing - Clinical Laboratory Consulting - Medical Practice Assessment -
Medical Personnel Management - Operational and Practice Management - Medical Tests - Respiratory Testing -
Laboratory Consulting - Healthcare Operational Management - Arterial Blood Gas Analysis - Overnight & Exertion Oximetry Testing -
Pulmonary Function Testing - Limited Pulmonary Stress Testing - EKG Testing
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who
are either age 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965, by President Lyndon
B. Johnson as amendments to Social Security legislation. At the bill-signing ceremony President Johnson enrolled former President Harry
S. Truman as the first Medicare beneficiary and presented him with the first Medicare card.
The Centers for Medicare Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), administers
Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and the Clinical Laboratory Improvement Amendments (CLIA).
Along with the Departments of Labor and Treasury, CMS also implements the insurance reform provisions of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). The Social Security Administration is responsible for determining Medicare
eligibility and processing premium payments for the Medicare program.
The Chief Actuary of CMS is responsible for providing accounting information and cost-projections to the Medicare Board of Trustees in
order to assist them in assessing the financial health of the program. The Board is required by law to issue annual reports on the
financial status of the Medicare Trust Funds, and those reports are required to contain a statement of actuarial opinion by the Chief
Since the beginning of the Medicare program, CMS has contracted with private companies to assist with administration. These contractors
are commonly already in the insurance or home health care area. Contracted processes include claims and payment processing, call center
services, clinician enrollment, and fraud investigation.
Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment
Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid
by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided
a maximum amount of wages, etc., on which the Medicare tax could be imposed each year. Beginning January 1, 1994, the compensation
limit was removed. In the case of self-employed individuals, the tax is 2.9% of net earnings from self-employment, and the entire
amount is paid by the self-employed individual.
In general, individuals are eligible for Medicare if they are a U.S. citizen or have been a permanent legal resident for 5 continuous
years, and they are 65 years or older, or they are under 65, disabled and have been receiving either Social Security or the Railroad
Retirement Board disability benefits for at least 24 months, or they get continuing dialysis for permanent kidney failure or need a
kidney transplant, or they have Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's disease).
Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a
certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no
Part A premium), and also pay any drugs that are not covered by Part D.
In 2007, Medicare provided health care coverage for 43 million Americans. Enrollment is expected to reach 77 million by 2031, when the
baby boom generation is fully enrolled.
The "Original Medicare" program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases
exist where prescription drugs are covered by Original Medicare, but as of January 2006, Medicare Part D provides more comprehensive
drug coverage. Medicare Advantage plans are another way for beneficiaries to receive their Part A, B and D benefits.
The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days
would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2008, $128.00 per day). Many insurance
companies have a provision for skilled nursing care in the policies they sell.
As with all Medicare benefits, Part B coverage is subject to medical necessity. Complex rules are used to manage the benefit, and
advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are
known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by
a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003.
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits
through private health insurance plans, instead of through the Original Medicare plan (Parts A and B). These programs were known as
"Medicare+Choice" or "Part C" plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the
compensation and business practices changed for insurers that offer these plans, and "Medicare+Choice" plans became known as "Medicare
Advantage" (MA) plans.
Original Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or
doctor in the country. For people who choose to enroll in a Medicare private health plan, Medicare pays the private health plan a set
amount every month for each member. Members may have to pay a monthly premium in addition to the Medicare Part B premium and generally
pay a fixed amount (a copayment of $20, for example) every time they see a doctor. The copayment can be higher to see a specialist.
The private plans are required to offer a benefit "package" that is at least as good as Medicare's and cover everything Medicare
covers, but they do not have to cover every benefit in the same way. Plans that pay less than Medicare for some benefits, like skilled
nursing facility care, can balance their benefits package by offering lower copayments for doctor visits. Private plans use some of
the excess payments they receive from the government for each enrollee to offer supplemental benefits. Some plans put a limit on
their members' annual out-of-pocket spending on medical care, providing some insurance against catastrophic costs over $5,000, for
example. But many plans use the excess subsidies to offer dental coverage and other services not covered by Medicare and can leave
members exposed to high medical bills if they fall seriously ill. Private plan members can end up with unexpectedly high out-of-pocket
In 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the
additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in
other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more. Medicare Advantage Plans that also include
Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MAPD.
Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000
during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are
enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties
is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans;
most have access to three or more. The number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in
2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.
Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the
passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare
must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These
plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance
companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of
drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The
exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough
suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are
required to repay CMS if they are found to have billed Medicare in these cases.
It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid will pay for drugs not
covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more quarters in which they paid
Federal Insurance Contributions Act taxes. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment
may purchase Part A for a monthly premium of:
All Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2008 is $96.40 per month. A
new income-based premium schema has been in effect for 2007, wherein Part B premiums are higher for beneficiaries with incomes
exceeding $80,000 for individuals or $160,000 for married couples. Depending on the extent to which beneficiary earnings exceed the
base income, these higher Part B premiums are $122.20, $160.90, $199.70, or $238.40 for 2008, with the highest premium paid by
individuals earning more than $205,000, or married couples earning more than $410,000.
Some people elect to purchase a type of supplemental coverage, called a Medigap plan, to help fill in the holes in Original Medicare
(Part A and B). These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some
Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare
Part D on January 1, 2006 are prohibited from covering drugs.
Some have suggested that by reducing the cost-sharing requirements in the Medicare program, Medigap policies increase the use of home
health care by Medicare beneficiaries and thus increase Medicare spending. One recent study suggests that this concern may have been
overstated due to methodological problems in prior research.
Medicare contracts with regional insurance companies who process over one billion fee-for-service claims per year. In 2003, Medicare
accounted for almost 13% of the entire federal budget. Based on the CMS projections, 33 cents of every dollar spent on health care in
the U.S. is paid by Medicare and Medicaid (including State funding). Looked at from three different perspectives, 61 cents of every
dollar spent on nursing homes, 47 cents of every dollar received by U.S. hospitals, and 27 cents of every dollar spent on physician
services is funded by Medicare or Medicaid.
For institutional care such as hospital and nursing home care, Medicare uses prospective payment systems. A prospective payment system
is one in which the health care institution receives a set amount of money for each episode of care provided to a patient, regardless
of the actual amount of care used. The actual allotment of funds is based on a list of diagnosis-related groups (DRG). The actual
amount depends on the kind of diagnosis made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the
patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However,
if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "upcoding," when a physician
makes a more severe diagnosis to hedge against accidental costs.
Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated
physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's
reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to
measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991,
the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.
The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. Firstly, it introduced the
Medicare Fee Schedule, which took effect in 1992. Secondly, it limited the amount Medicare non-providers could balance bill Medicare
beneficiaries. Thirdly, it introduced the Medicare Volume Performance Standards (MVPS) as a way to control costs.
On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS). The MFS assigned Relative Value Units (RVUs) for each procedure
from the Resource-Based Relative Value Scale (RBRVS). The Medicare reimbursement for a physician was the product of the RVU for the
procedure, a Geographic Adjustment Factor (GAF) for geographic variations in payments, and a global Conversion Factor (CF) which
converts RBRVS units to dollars.
According to the 2004 "Green Book" of the House Ways and Means Committee, Medicare expenditures from the American government were
$256.8 billion in fiscal year 2002. Beneficiary premiums are highly subsidized, and net outlays for the program, accounting for the
premiums paid by subscribers, were $230.9 billion.
Medicare spending is growing steadily in both absolute terms and as a percentage of the federal budget. Total Medicare spending reached
$440 billion for fiscal year 2007, or 16 percent of all federal spending. The only larger categories of federal spending are Social
Security and defense. Given the current pattern of spending growth, maintaining Medicare's financing over the long-term may well
require significant changes.
According to the 2008 report by the board of trustees for Medicare and Social Security, Medicare will spend more than it brings in from
taxes this year (2008). The Medicare hospital insurance trust fund will become insolvent by 2019. Shortly after the release of the
report, the Chief Actuary testified that the insolvency of the system could be pushed back by 18 months if Medicare Advantage plans
were paid at the same rate as the traditional fee-for-service program. He also testified that the 10-year cost of Medicare drug
benefit is 37% lower than originally projected in 2003, and 17% percent lower than last year's projections.
Spending on Medicare and Medicaid is projected to grow dramatically in coming decades. While the same demographic trends that affect
Social Security also affect Medicare, rapidly rising medical prices appear a more important cause of projected spending increases.
The Congressional Budget Office (CBO) has indicated that: "Future growth in spending per beneficiary for Medicare and Medicaid - the
federal government's major health care programs-will be the most important determinant of long-term trends in federal spending.
Changing those programs in ways that reduce the growth of costs-which will be difficult, in part because of the complexity of health
policy choices-is ultimately the nation's central long-term challenge in setting federal fiscal policy." Further, the CBO also projects
that "total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in
2082-which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk
of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of
beneficiaries associated with an aging population."
The fundamental problem is that the ratio of workers paying Medicare taxes to retirees drawing benefits is shrinking at the same time
that the price of home health care services per person is increasing. Currently there are 3.9 workers paying taxes into Medicare for
every older American receiving services. By 2030, as the baby boom generation retires, that is projected to drop to 2.4 workers for
each beneficiary. Medicare spending is expected to grow by about 7 percent per year for the next 10 years. As a result, the financing
of the program is out of actuarial balance, presenting serious challenges in both the short-term and long-term.
Medicare funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits
through payments called Direct Medical Education payments. Medicare also uses taxes for Indirect Medical Education, a subsidy paid to
teaching hospitals in exchange for training resident physicians. Overall funding levels, however, have remained frozen over the last
ten years, creating a bottleneck in the training of new physicians in the US. Meanwhile, the US population continues to grow, leading
to greater demand for physicians. At the same time the cost of medical services continue rising rapidly and many geographic areas face
physician shortages, both trends suggesting the supply of physicians remains too low. Medicare finds itself in the odd position of
having assumed control of graduate medical education, currently facing major budget constraints, and as a result, freezing funding
for graduate medical education, as well as for physician reimbursement rates. This halt in funding in turn exacerbates the exact
problem Medicare sought to solve in the first place: improving the availability of medical care. In response, teaching hospitals
have resorted to alternative approaches to funding resident training, leading to the modest 4% total growth in residency slots
from 1998-2004, despite Medicare funding having been frozen since 1996.