The Medicare Advantage Program

946 Words2 Pages
bulb-icon

Recommended: The balanced budget act of 1997

Medicare Advantage Program/ Medicare+Choice: Part C
The Balanced Budget Act of 1997 created Part C to allow individuals to choose private plans as alternatives to Parts A and B. Private plans must include at least all services offered in Parts A and B, and may include reduced cost sharing or premiums. Part C is paid for by the HI trust fund and the Part B SMI trust fund, and is proportional to the amount of benefits paid by Parts A and B. Administrative costs for Part C totaled 1.4% in 2008. Beneficiary payments vary by plan, and are based on capitation; beneficiaries pay a fixed monthly amount regardless of the actual services used (Klees et al., 2009).
Fraud
Medicare is susceptible to fraud due to its size and complicated structure. Fraud ranges from accidental errors in the accuracy of claims to intentional billing abuse. Providers are expected to submit truthful claims, which are then checked by contracted intermediaries that oversee payment. Quality Improvement Organizations (QIOs), Medicare Integrity Programs (MIPs), and the Department of Justice (DOJ) are some of the numerous groups tasked with the prevention and recovery of fraudulent payments.
QIOs are “groups of practicing health care professionals who are paid by the Federal government to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries” (Klees et al., 2009, p. 16). Among the responsibilities of QIOs is to verify “that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting” (Klees, 2009, p. 14).
MIPs were created in 1996 under the Health Insurance Portability and Accountability Act (HIPAA). MIPs provide monies for the CMS or contrac...

... middle of paper ...

...ve no other health insurance. CHIP was allocated $40 billion of federal funding through 2007. An additional $10 billion was spent in 2008, and in 2009, federal funding was extended to 2013. States were also given the option of providing coverage through the expansion of their Medicaid programs. The federal government pays an “enhanced” FMAP, averaging 71.36% in 2009, for CHIP (Klees et al., 2009).
PACE is a state option created by the Balanced Budget Act to provide nursing facility level care to individuals 55 and older as an alternative to institutionalization. Participating providers are paid solely through PACE, and are required to provide all services included in Medicare and Medicaid coverage regardless of the actual duration or extent of services. Providers cannot charge additional deductibles, copayments, or other fees on beneficiaries (Klees et al., 2009).

Show More
Related

  • Canada Healthcare System vs. The United States Healthcare Systems

    1490 Words  | 3 Pages

    Due to the Patient Protection and Affordable Care Act signed into law on March 23rd, 2010; health care in the US is presently in a state of much needed transition. As of 2008, 46 Million residents (15% of the population) were uninsured and 60% of residents had coverage from private insurers. 55% of those covered by private insurers received it through their employer and 5% paid for it directly. Federal programs covered 24% of Americans; 13% under Medicare and10% under Medicaid. (Squires, 2010)

    Read More

  • Medicare Part D

    1800 Words  | 4 Pages

    The United States of America accounts for only 5% of the world’s population, yet as a nation, we devour over 50% of the world’s pharmaceutical medication and around 80% of the world’s prescription narcotics (American Addict). The increasing demand for prescription medication in America has evoked a national health crisis in which the government and big business benefit at the expense of the American public.

    Read More

  • The Stark Law

    1743 Words  | 4 Pages

    Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”

    Read More

  • Organizational Systems And Quality Leadership

    1835 Words  | 4 Pages

    Healthcare in the U.S. has recently been affected by implementation of the Affordable Care Act (ACA) of 2010. The intent is to create a healthca...

    Read More

  • Hipaa Privacy Rule

    1950 Words  | 4 Pages

    If you believe a health care provider or health plan has violated your privacy you have the right to file a complaint with your health care provider and with DHHS.

    Read More

  • The Reluctant Welfare State

    2100 Words  | 5 Pages

    It covers ambulatory care and physician fees. There is a deductible and there are sometimes co-pays as well. Part C is presented as an alternative to Parts A and B. This is where private insurance companies can contract with the federal government to offer Medicare benefits through their own policies. It can offer benefits not covered under original Medicare, although there might be a premium charged.

    Read More

  • The Pros And Cons Of Health Care

    639 Words  | 2 Pages

    Above all, if all states have decide to follow through ObamaCare's Medicaid Expansion they will conjointly pay $76 billion to insure up to 21.3 Million individuals who don't have access to health insurance for over the next decade. Regardless of what state, the federal government will help pay for 93% of the state cost of healthcare. Medicaid Expansion is a great way to help families below the federal poverty line get insurance and stay healthy. Without it, they will fall between the cracks forcing them to use Obamacare. In that case, it is projected to drive up cost of insurance for Americans.

    Read More

  • The Medicare Prescription Drug, Improvement, and Modernization Act of 2003

    1632 Words  | 4 Pages

    On December 8, 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act of 2003 (Pub. L. 108-173).  This landmark legislation provides seniors and individuals with disabilities with a prescription drug benefit, more choices, and better benefits under Medicare. It produced the largest overhaul of Medicare in the public health program's 38-year history. The MMA was signed by President George W. Bush on December 8, 2003, after passing in Congress by a close margin. One month later, the ten-year cost estimate was boosted to $534 billion, up more than $100 billion over the figure presented by the Bush administration during Congressional debate. The inaccurate figure helped secure support from fiscally conservative Republicans. It was reported that an administration official, Thomas A. Scully, had concealed the higher estimate and threatened to fire Medicare Chief Actuary Richard Foster if he revealed it. By early 2005, the White House Budget had increased the 10-year estimate to $1.2 trillion.

    Read More

  • Medicare Essay

    1043 Words  | 3 Pages

    There are four components to the Medicare program, part A, B, C and D. Part A of Medicare covers in patient hospital services; patients have a financial responsibility to cover a deductible that is equivalent to 1 day of hospitalization, thereafter cost is covered at 100 percent for a maximum of 60 days. This also includes nursing facilities, home and hospice care. Part B covers outpatient surgery and physician office visits. This is an elective component of Medicare in that there is a premium associated with this plan that is paid for directly through social security payments. Part C is know as Medicare Advantage and is a supplemental policy that is purchased directly from employers; one may be denied for health reasons depending one when the plan is acquired. Part D is prescription drug coverage that is eligible to all individuals that qualify for Medicare. Beneficiaries of the Medicare choose which prescription plan they want and pay a corresponding monthly premium.

    Read More

  • Medicare Fraud

    999 Words  | 2 Pages

    Medicare fraud occurs when healthcare providers, suppliers, and private companies charge for services or supplies patients never receive. Additionally, abuse of the Medicare program also occurs because physicians and suppliers do not always follow best medical practices which leads to excessive costs through improper payments, or medically unnecessary services, both of which abuse the program. Conservative estimates suggest he...

    Read More

  • Medicare and Medicaid

    2099 Words  | 5 Pages

    Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.

    Read More

  • The Medicare Problem

    2703 Words  | 6 Pages

    The two major components of Medicare, the Hospital Insurance Program (Part A of Medicare) and the supplementary Medical Insurance program (Part B) may be exhausted by the year 2025, another sad fact of the Medicare situation at hand (“Medicare’s Future”). The burden brought about by the unfair dealings of HMO’s is having an adverse affect on the Medicare system. With the incredibly large burden brought about by the large amount of patients that Medicare is handed, it is becoming increasingly difficult to fund the system in the way that is necessary for it to function effectively. Most elderly people over the age of 65 are eligible for Medicare, but for a quite disturbing reason they are not able to reap the benefits of the taxes they have paid. Medicare is a national health plan covering 40 mi...

    Read More

  • Summary: Medicare Advantage Training

    82 Words  | 1 Pages

    The Training department is ready to roll out Medicare Advantage training today. We have selected Edwards, Cory , Solache, Melissa, Smith, Adrianna, Hurtado, Delilah , Stooksbury, Jackie and Correa, Mirian for the core support team. We are requesting for assistance with the best time frame to start our training, we will have one on one training with each representative for 30-45mins. Training will send out invites to each representative for training times and CC: supervisors and Tammy to ensure communication.

    Read More

  • American’s Health-Care Crisis

    779 Words  | 2 Pages

    Baicker, K., Chadra, A. (2004, April 7). Medicare Spending, the Physician workforce and beneficiaries’ quality

    Read More

  • Fraud and Abuse in the Healthcare System

    913 Words  | 2 Pages

    Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very educated people including business people, hospital, doctors, and administrators.

    Read More

More about The Medicare Advantage Program

Open Document