Module 2 – Home

MEDICARE ELIGIBILITY AND FINANCING

Modular Learning Outcomes

Upon successful completion of this module, the student will be able to satisfy the following outcomes:

• Case
  • Investigate the eligibility, financing, and reimbursement rules of the Medicare program.
  • Compare and contrast the level of financial reimbursement for Medicare patients vs. those with private health care insurance.
• SLP
  • Assess both the service coverages and the service gaps of the Medicare program.
  • Calculate the likely annual out-of-pocket costs for a Medicare patient, given a scenario.
• Discussion
  • Analyze both the affordability and financial sustainability of the Medicare program.

Module Overview

In 1965, the Medicare program was created to provide health insurance coverage for people ages 65 and older, regardless of their income, medical history, or heath status. Prior to the creation of Medicare, only about half of Americans had health insurance to help them access and pay for medical services. Many could not obtain health insurance because the premiums were unaffordably high, and/or because they were denied coverage on the basis of age or having a pre-existing condition. Medicare’s coverage allowed millions of older Americans and people with certain disabilities to freely access the health care system for the first time. It did not cover all expenses, but it did make access to services much more possible and affordable. The economic effects of Medicare have been significant for both its beneficiaries as well as the health systems providing the services.

A few years later in 1972, the Medicare program was expanded to cover persons under age 65 if they had a long-term disability or particular health conditions (e.g., amyotrophic lateral sclerosis, permanent kidney failure/end stage renal disease, etc.). Medicare remains a key source of coverage and payment in today’s health care market, providing access to health services to over 60 million older Americans as well as younger persons with certain disabilities and long-term illnesses. Medicare is broken down into several portions, each covering specific items such as hospitalizations, physician care, prescription drugs, skilled nursing care, therapy services, and palliative/hospice care. Currently, Medicare is financed by a part of the payroll taxes paid by workers and their employers. The program also receives financing through monthly premiums that are deducted from Social Security checks. Let’s learn more about this important program, its coverages, and its financing.

Module 2 – Background

MEDICARE ELIGIBILITY AND FINANCING

Required Reading/Viewing

Andersen, M. (2018). Effects of Medicare coverage for the chronically ill on health insurance, utilization, and mortality: Evidence from coverage expansions. Journal of Health Economics, Vol. 60, 75-89. Available in the Trident Online Library.

Centers for Medicare & Medicaid Services. (2019). Medicare current beneficiary survey. Available at  www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index.html.

Centers for Medicare and Medicaid Services. (2019). Medicare program: General information. Available at  https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

Cubanski, J., & Boccuti, C. (2015). Medicare coverage, affordability, and access. Generations, 39(2), 26-34. Available in the Trident Online Library.

Kaiser Family Foundation. (2019). An overview of Medicare. Available at
http://files.kff.org/attachment/issue-brief-an-overview-of-medicare

Module 2 – Case

MEDICARE ELIGIBILITY AND FINANCING

Assignment Overview

An awareness of the covered and noncovered services of Medicare is a critical area of understanding for health care managers. The program has grown and changed over time, refining who and what is included vs. excluded. The Case presents the opportunity to investigate these coverages, as well as the financing of Medicare. Specific reimbursement rules are in place that must be followed if funds are to be received for providing services. The level of Medicare reimbursement differs from what would be received from private insurance – but by how much – and how can this affect your bottom line?

Case Assignment

Using the information in the required readings, as well as some additional research in peer-reviewed sources, complete your Case assignment by answering the following:

1. Investigate the eligibility of the Medicare program; who can be covered?
2. How is the Medicare program financed? What specific operating rules must be followed to receive reimbursement funds?
3. How does the average Medicare reimbursement level specifically compare to the average reimbursement for private insurance? How can this difference affect the bottom line at your facility?

Assignment Expectations

1. Conduct additional research to gather sufficient information to support your analysis.
2. Provide a response of 3-5 pages, not including title page and references.
3. There are multiple required items to be addressed herein; please use subheadings to show where you are responding to each required item and to ensure that none are omitted.
4. Support your paper with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals:
   Angelo State University Library. (n.d.). Library Guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www.angelo.edu/services/library/handouts/peerrev.php
5. You may use the following source to assist in formatting your assignment:
   Purdue Online Writing Lab. (n.d.). General APA guidelines. Retrieved from https://owl.english.purdue.edu/owl/resource/560/01/.
6. For additional information on reliability of sources, review the following source:
   Georgetown University Library. (n.d.). Evaluating internet resources. Retrieved from https://www.library.georgetown.edu/tutorials/research-guides/evaluating-internet-content

Module 2 – SLP

MEDICARE ELIGIBILITY AND FINANCING

Using the information in the background readings as well as some research in peer-reviewed sources of your own, create a professional-looking PowerPoint presentation of 10-14 slides (not including the title slide or the reference slide) which clearly summarizes each of the items below. Include thorough speaker’s notes to further expand upon and explain your points. Use in-text citations on your slides, as well as a reference slide at the end of the presentation.

1. Break down the four portions of the Medicare program (A, B, C, D). What coverage is provided by each portion?
2. What are the specific gaps in coverage (what is not covered)?
3. What are Medigap and Medicare Advantage plans? Would you enroll in one when you are 65 – why or why not?
4. Today is your 65th birthday! You are now enrolled in Medicare for the first time. In a chart, calculate your likely out-of-pocket coverage costs for one year – how much will you need to pay towards your care? You are relatively healthy, consistently using both well-adult visits and age-appropriate preventive health care services each year, but you will definitely need a total knee replacement in this calendar year. Include premium deductions, copays, etc., showing your calculations in your chart. Are your out-of-pocket costs more or less than you expected?

SLP Assignment Expectations

1. Conduct additional research to gather sufficient information to support your presentation.
2. Provide 10-14 quality PowerPoint slides of bullet-point information content (with speaker’s notes), not including title page and reference slides. Use in-text citations on the slides.
3. Support your paper with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals:
   Angelo State University Library. (n.d.). Library Guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www.angelo.edu/services/library/handouts/peerrev.php
4. You may use the following source to assist in formatting your assignment:
   Purdue Online Writing Lab. (n.d.). General APA guidelines. Retrieved from https://owl.english.purdue.edu/owl/resource/560/01/.
5. For additional information on reliability of sources, review the following source:
   Georgetown University Library. (n.d.). Evaluating internet resources. Retrieved from https://www.library.georgetown.edu/tutorials/research-guides/evaluating-internet-content

Module 2 – Outcomes

MEDICARE ELIGIBILITY AND FINANCING

• Module
  • Investigate the eligibility, financing, and reimbursement rules of the Medicare program.
  • Compare and contrast the level of financial reimbursement for Medicare patients vs. those with private health care insurance.
  • Assess both the service coverages and the service gaps of the Medicare program.
  • Calculate the likely annual out-of-pocket costs for a Medicare patient, given a scenario.
  • Analyze both the affordability and financial sustainability of the Medicare program.
• Case
  • Investigate the eligibility, financing, and reimbursement rules of the Medicare program.
  • Compare and contrast the level of financial reimbursement for Medicare patients vs. those with private health care insurance.
• SLP
  • Assess both the service coverages and the service gaps of the Medicare program.
  • Calculate the likely annual out-of-pocket costs for a Medicare patient, given a scenario.
• Discussion
  • Analyze both the affordability and financial sustainability of the Medicare program.

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Module 2 Discussion: The Affordability and Financial Sustainability of Medicare

 

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After researching the affordability and financial sustainability of the Medicare program, discuss whether or not the Medicare program is reasonably affordable for its beneficiaries – why or why not? Is the program financially sustainable for future generations, given the retirement of the baby boomers and the shrinking of the active taxpaying workforce numbers? What changes could be proposed now/soon to save Medicare? Provide responses based on facts to each of these items (with credible/peer-reviewed citations) in a 200-word supported analysis. Remember to use in-text citations in your post.

Your posts will be graded on how well they meet the Discussion Requirements posted in the “Before You Begin” section”. Please review this section, as well as the discussion scoring rubric.