Third Party Payers: Government Health Plans (Nursing)

by Heide Cygan, DNP, RN

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    00:01 Now we're going to talk about a type of third party payer or government supported health plans.

    00:07 We'll cover Medicare, Medicaid, and CHIP, our children's health insurance plan.

    00:14 Let's start first with Medicare.

    00:17 Medicare provides federal health insurance for adults aged 65 years and older who've paid into the Social Security system.

    00:25 About 85% of our Medicare beneficiaries are over the age of 65.

    00:30 The remaining 15% are younger than 65, but have a permanent disability or chronically ill, including those with end stage renal disease.

    00:41 Financing of Medicare is through general tax revenues, payroll taxes, and premiums paid by beneficiaries.

    00:50 Now, there's a common misconception that Medicare is free, that anyone over the age of 65 in the United States gets free health care.

    00:58 Well, let me explain the four different parts of Medicare and this will show you how Medicare is far from free health care.

    01:05 Let's start with part A.

    01:07 This is called the hospital insurance plan.

    01:10 And this is the part of Medicare that's free to its beneficiaries.

    01:13 It's covered strictly through taxes.

    01:15 This part of Medicare covers only inpatient hospital stays, and very limited skilled nursing care, some home health, and again, very limited hospice services.

    01:26 It's important to understand that this does not cover any other service, no primary care visits, no labs, no tests, no medications.

    01:34 But again, this is the part of Medicare that doesn't require a monthly premium.

    01:39 Next we have Medicare Part B.

    01:41 This is preventative insurance.

    01:42 It's a supplementary and voluntary medical insurance program.

    01:46 It primarily covers provider services, and also covers some home health care for beneficiaries that aren't covered under Part A.

    01:54 In order to have Part B, you must pay a monthly premium to the government.

    02:00 Then we have Part C.

    02:01 This is also known as Medicare Advantage.

    02:04 These are private insurance plans that are subsidized by the federal government.

    02:09 Part C plans are not supplemental to A and B, instead they take the place of Parts A and B.

    02:15 Some may also cover vision, dental and prescriptions.

    02:18 Most people who are enrolled in Part C, pay the Part B premium and also pay an additional amount to the private insurance company.

    02:27 So part C is more expensive than Part B but it typically offers more coverage and offers more options for providers.

    02:34 Further, with Parts B and C, there are additional out of pocket expenses like co-pays and deductibles just like you would have with a private insurance company.

    02:45 Here we have Part D.

    02:47 This is the prescription medication benefit.

    02:49 These plans are offered by private companies but supported through governmental funds.

    02:54 Part D plans can be combined with either Part A and B or with Part C Medicare Advantage.

    03:00 Either way, there's an additional monthly premium for this benefit.

    03:03 In addition, their out of pocket expenses for prescriptions, just like you would have with a private insurance plan.

    03:10 Okay, let's move on and talk about Medicaid.

    03:13 Medicaid provides health insurance for children, for pregnant women, for parents with dependent children, for seniors, and for people with severe disabilities.

    03:25 Medicaid is jointly funded between the federal and state governments.

    03:29 It's meant to assist states in providing adequate medical care for eligible individuals.

    03:34 Now, Medicaid is an optional program for states, but right now, all states participate.

    03:40 Over time, the scope of Medicaid has increased.

    03:43 In states, opting to provide Medicaid had been required to implement these changes over time.

    03:49 If not, they lose their federal Medicaid funding.

    03:53 For example, prior to the Affordable Care Act, childless adults without disabilities were not eligible for Medicaid.

    04:00 But under the Affordable Care Act, Medicaid was expanded to all non-elderly adults with incomes up to 138% of the federal poverty level.

    04:11 The Affordable Care Act initially required all states to expand Medicaid to cover these individuals.

    04:17 But this was legally challenged by several states leading to a Supreme Court case.

    04:22 The courts ruled that Medicaid expansion was unconstitutional.

    04:26 Although states participating in Medicaid had been required to comply with all of its provisions, the Supreme Court ruled, stating that the increase was too sudden, and the penalty for withholding existing Medicaid funds for non compliance was too high.

    04:40 So currently, there is no deadline for when states can adopt this expansion.

    04:45 However, 37 states have opted to expand Medicare and cover this population.

    04:52 Okay, now moving on to CHIP.

    04:54 The children's health insurance plan.

    04:57 This provides health coverage to uninsured children under the age of 19.

    05:02 This is really meant to assist families caught in the gap between Medicaid and affordable private health insurance.

    05:09 The majority of funding for CHIP programs comes from federal dollars.

    05:13 As you may remember, this was a big reason for the government shutdown in January of 2018.

    05:18 CHIP funding had only been approved through the end of 2017.

    05:22 And that meant that without further approval, states had to fund their entire programs.

    05:26 And many states didn't have enough money to fund their programs, which would have meant a reduction of coverage.

    05:32 But in January 2018, Congress came to an agreement and CHIP was funded.

    05:36 It was funded through fiscal year 2023.

    05:41 The publicly funded health care system in the United States is complex.

    05:44 What's important to understand is that each of these programs is designed to protect the health of the public by providing insurance coverage for those who would otherwise not have a way to pay for health care.

    05:54 Programs like these work to decrease health disparities, and improve health outcomes for those who need it the most.

    About the Lecture

    The lecture Third Party Payers: Government Health Plans (Nursing) by Heide Cygan, DNP, RN is from the course Public Health and Policy (Nursing).

    Included Quiz Questions

    1. The 30-year-old with muscular dystrophy who uses a wheelchair to mobilize.
    2. The 70-year-old who has been paying into the social security system.
    3. The 60-year-old retiree with no disabilities or chronic health conditions.
    4. The 30-year-old with three dependent children.
    5. The 5-year-old with no disabilities or chronic health conditions.
    1. 37 states now offer coverage for childless adults without chronic illnesses.
    2. It is funded solely by the state government.
    3. It is mandatory for each state to offer Medicaid.
    4. It only covers those under 65.
    1. Medicaid
    2. CHIP
    3. Medicare
    4. Blue Shield
    5. Care Source

    Author of lecture Third Party Payers: Government Health Plans (Nursing)

     Heide Cygan, DNP, RN

    Heide Cygan, DNP, RN

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