What is the largest third party payer in the United States?
the government via Medicare
Medicare is a significant source of healthcare funding in the U.S.
In what year was Medicare established?
1965
It was established with the passage of the Social Security Act.
Who is eligible for Medicare benefits?
- Individuals 65+
- People with disability benefits from Social Security
- Individuals with end stage renal disease
Eligibility expanded in 1972 to include more groups.
What does Part A of Medicare cover?
- Hospital care
- Hospice care
- Some home care services
It pays for the cost of hospital/facility care.
What does Part B of Medicare cover?
- Physician services
- Durable Medical Equipment (DME) not covered under Part A
It is supplemental medical insurance.
Who is responsible for the administration of the Federal Medicare program?
Secretary of the Department of Health and Human Services
This individual oversees the Medicare program.
What organization operates Medicare?
Centers for Medicare and Medicaid Services (CMS)
CMS also oversees Medicaid and CHIP.
What is the role of Medicare Administrative Contractors (MACs)?
- Handle paperwork for Medicare
- Usually insurance companies that bid for contracts with CMS
They manage daily operations of Medicare.
How is the flow of money structured in Medicare?
SSA → through CMS → MACs → paid to beneficiaries and providers
This outlines the financial process in Medicare.
What percentage of costs does Medicare typically cover?
80%
Beneficiaries pay the remaining 20% as coinsurance.
What are Quality Improvement Organizations (QIOs)?
- Improve quality of care for beneficiaries
- Protect integrity of the Medicare Trust Fund
- Address individual complaints
They work to enhance care delivery systems.
What are the two types of complaints handled by QIOs?
- Beneficiary and Family Centered Care (BFCC)
- Quality Innovation Network (QIN)
These types focus on quality of care and appeals.
What does Part C of Medicare refer to?
Medicare Advantage Organizations
It includes various healthcare plans beneficiaries can choose from.
What does Part D of Medicare cover?
Prescription drugs
Established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
What act enacted measures to ensure certain prescription drug prices stay in line with inflation?
The Inflation Reduction Act of 2022
This act aims to control drug pricing.
