Problems With Medicare And Medicaid


Poverty And Illness In The Elderly Population

Problems With Medicare, Medicaid and Social Security

Despite general improvements in the economic situation of the elderly population over the last 3 decades, many elderly Americans continue to struggle to pay living expenses on low or modest incomes. Forty-one percent of the Nation’s 31 million elderly people living in the community have incomes below twice the Federal poverty level and 1 in 5 are poor or near-poor .

In 1994, the FPL was $7,100 per year in income for a single elderly adult and $9,000 for an elderly couple. Twelve percent of the elderly population3.7 million people had incomes below the poverty level and another 7 percent2.2 million people were near-poor with incomes between 100 and 125 percent of FPL . Together, these 5.9 million poor and near-poor people comprise Medicare’s non-institutionalized low-income elderly population. Another 1.4 million elderly reside in nursing homes and receive assistance from Medicaid .

Distribution of Elderly, by Poverty Level: 1994Percent of the Elderly Who Are Low-Income, by Age, Sex, and Race: 1994Characteristics of Elderly Medicare Beneficiaries: 1992Percent of Elderly Medicare Beneficiaries Reporting Fair or Poor Health: 1992Percent of Elderly Medicare Beneficiaries With Selected Conditions: 1992Percent of Elderly Medicare Beneficiaries Needing Help With ADL Limitations: 1992

Full Benefit Vs Partial Benefit: The Different Levels Of Medicaid Help

As long as youre entitled to Medicare Part A and B, and are eligible for some form of Medicaid benefit, then youre dual-eligible. However, not all dual-eligible benefits are the same.

If you are awarded Medicaid, your benefits will fall into one of the following categories of financial assistance. Medicaid can even pay for your Medicare Part D drug plan in some circumstances. Heres a brief overview of how each program works.

Traditional Medicare And Medicare Advantage: A Historic Divide

Beneficiaries weigh considerable trade-offs when deciding whether to enroll in Medicare Advantage plans or traditional Medicare. Unlike the latter, Medicare Advantage plans are required to place limits on enrollees out-of-pocket spending and to maintain provider networks.3 The plans also can provide benefits not covered by traditional Medicare, such as eyeglasses, fitness benefits, and hearing aids. Medicare Advantage plans are intended to manage and coordinate beneficiaries care. Some Medicare Advantage plans specialize in care for people with diabetes and other common chronic conditions, including Special Needs Plans SNPs also focus on people who are eligible for both Medicare and Medicaid and those who require an institutional level of care.

Traditional Medicare and Medicare Advantage enrollees have historically had different characteristics, with Medicare Advantage enrollees somewhat healthier.4 Black and Hispanic beneficiaries and those with lower incomes have tended to enroll in Medicare Advantage plans at higher rates than others.5 Traditional Medicare has historically performed better on beneficiary-reported metrics, such as provider access, ease of getting needed care, and overall care experience.6

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Medicare And Medicaid Essay

Statement of ProblemMedicare 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

Medicare As A Form Of National Health Insurance

Medicare and Medicaid: A Reference Handbook (Contemporary ...

By 1961, a Medicare bill had received the endorsement of President John F. Kennedy, and a long campaign for its congressional passage began. By now, the idea of national health insurance had undergone, if not another transformation, then at least a major change in an effort to find common ground with private health care providers. Wilbur Cohen, who coordinated the legislative activities related to Medicare for Presidents Kennedy and Johnson, expressed what the legislation would not do, rather than what it would do. said that the proposal would â⦠not provide a single medical serviceâ¦physicians’ services would not be covered or affected and the proposal provides that the government would exercise no supervision or control over the administration or operation of participating institutions or agencies.â Beyond the political expediency of restricting benefits to the elderly and concentrating on hospital, rather than physician care, the limits that Cohen set on Medicare reflected the increasing prominence of the hospital as a provider of medical care .

Important to Javits’ proposals and to other alternatives offered at the time was the notion of choice. Representative John Lindsay , proposed that consumers be given a fundamental choice. They could either accept government health insurance, to be run by the States, or a private health care plan. If they chose the private health plan, they would receive an increase in their social security benefits.

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Close To Dual Eligibility Check With Your States Medicaid Office

As part of the Affordable Care Act, each state was allowed to broaden its Medicaid assistance levels. Some states agreed to expand coverage but others did not. So dont automatically rule yourself out discuss your circumstances with your local social services provider.

The Medicare-Medicaid Coordination Office: Medicaid can be quite confusing. Complexity keeps some people from even applying for Medicaid, even though the application process is quite simple.

To help solve that problem, the federal government runs a Medicare-Medicaid Coordination Office. The office streamlines the experience of getting healthcare to those who need it. They work to develop insurance policies designed to work especially with dual-eligible citizens.

What About Medicare For All

Medicare for All, also known as universal or single-payer healthcare, is a concept youve heard about but might not know exactly how it works. There are different versions and proposals, but at its core, it means that nearly all Americans would have access to the type of government-funded healthcare currently provided only to those over 65 or disabled.

In some Medicare for All proposals, all Americans would be covered by the government program and private health insurance would be limited to offering only supplemental insurance for procedures not covered by the government program such as elective plastic surgery or hearing aids. Other versions maintain the private insurance industry but provide the government program as an option.

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The Formula For Higher Profits: Score Patients As Sicker Than They Are

Much of the debate centers on the complex method used to pay the health plans.

In original Medicare, medical providers bill for each service they provide. By contrast, Medicare Advantage plans are paid using a coding formula called a “risk score” that pays higher rates for sicker patients and less for those in good health.

That means the more serious medical conditions the plans diagnose the more money they get â sometimes thousands of dollars more per patient over the course of a year with little monitoring by CMS to make sure the higher fees are justified. According to whistleblower complaints calling out this practice of upcoding, three of the conditions frequently given a higher risk score by Medicare Advantage plans include cases of diabetes with complications, major depression and congestive heart failure.

Congress recognized the problem in 2005 and directed CMS to set an annual “coding intensity adjustment” to reduce Medicare Advantage risk scores and keep them more in line with original Medicare.

But since 2018, CMS has set the coding adjustment at 5.9%, the minimum amount required by law. Boccuti said that adjustment is “too low,” adding that health plans “are inventing new ways to increase their enrollees’ risk scores, which gain them higher monthly payments from Medicare.”

Centers For Medicare And Medicaid Services May Terminate Agreement With Montana State Hospital

Problems With Medicare, Medicaid and Social Security Part 4

WARM SPRINGS – The Montana State Hospital in Warm Springs has been placed on “Immediate Jeopardy” status by the Centers for Medicare and Medicaid Services . CMS sent a letter to the Montana State Hospital saying the hospital violated patient rights and infection prevention control.

CMS determined that the violations are so serious that its an immediate and serious threat to the health and safety of any individual who comes to the hospital to receive emergency services. CMS has given the hospital until March 13 to correct the problems.

In a statement, Jeremy Hoscheid, the Executive Director of the Mental Disabilities Board of Visitors, wrote:

“Immediate Jeopardy represents a situation in which noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. These situations need to be accurately identified by the surveyors, thoroughly investigated by the surveyors, and resolved by the provider as quickly as possible. IJ is the most serious deficiency type and carries the most serious sanctions for providers.”

If the hospital doesn’t correct the problems, the hospital will get its federal Medicaid/Medicare status revoked.

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The Best Option: Additional Revenue

Plenty of options are available. We could add new revenue, raise the share of costs shouldered by enrollees, or cut benefits – or reduce payments to healthcare providers. The Commonwealth Fund – a foundation focused on healthcare policy – recently published a series of blog posts by Medicare experts that does a good job of laying out these options and more. .

The solutions that make the most sense to me involve additional revenue. Cutting Medicare benefits just makes no sense, considering the precarious financial health of many retirees: half of Medicare beneficiaries lived on incomes below $29,650 in 2019 and 25% had incomes below $17,000, according to the Kaiser Family Foundation

Some of the Commonwealth Fund writers advocate further use of private-market competition to solve the problem, but I find these arguments unconvincing. The idea served up most frequently is premium support, a holdover idea from the last decade that would replace Medicares system of defined benefits with a defined government contribution – some would call it a voucher – that enrollees would use to buy in to either Original Medicare or privately offered Advantage plans.

Yet evidence shows that the marketplace approach already in place for prescription drug and Medicare Advantage plans does not work well . And in parts of the country where Original Medicare is more expensive than Advantage, this approach would create a lopsided playing field.

Consider Premiumsand Your Other Costs

To see how a Medicare Advantage Plan cherry-picks its patients, carefully review the copays in the summary of benefits for every plan you are considering. To give you an example of the types of copays you may find, here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida:

  • Hospital stay$175 per day for the first 10 days
  • Ambulance$300
  • Diabetes suppliesup to 20% copay
  • Diagnostic radiologyup to $125 copay
  • Lab servicesup to $100 copay
  • Outpatient x-raysup to $100 copay
  • Renal dialysisup to 20% copay

As this non-exhaustive list of copays demonstrates, out-of-pocket costs will quickly build up over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. The best candidate for Medicare Advantage is someone who’s healthy,” says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. “We see trouble when someone gets sick.”

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What If Your Doctor Only Accepts Medicare And Not Medicaid

Doctors are not required to accept Medicaid payment. Why? It requires more paperwork for them, and Medicaid reimbursements can be less than other forms of insurance. What can you do?

  • Remember that there are more than 70 million people on Medicaid. Therefore, many doctors are indeed treating people with Medicaid coverage.
  • If you already have a doctor you like, explain to him or her that you recently received Medicaid. They may continue to see you as a patient, even if they are not accepting other new patients on Medicaid. After all, you are an established patient of theirs.
  • You may have to put a little effort into finding doctors in your area who accept Medicaid payment. Try searching the physician finder websites in your area, ask your Medicaid contact person, and call individual doctors offices.
  • If a doctors office says they dont accept Medicaid, ask for a referral to a practice that does accept new Medicaid patients.

Aligning Medicare And Medicaid

Centers for Medicare and Medicaid Services issues ...

One of The SCAN Foundations recommendations: The U.S. government umbrella agency for Medicare and Medicaid The Centers for Medicare & Medicaid Services should align the implementation and oversight of programs serving individuals dually eligible for Medicare and Medicaid. Seems like a no-brainer, no?

But Chernof says this is a problem both on the conceptual level and on the operational level. He offers this example: To cover some home- or community-based services, Medicaid requires a denial letter from Medicare, but Medicare will say its not a benefit , so we cant deny it.

Another problem: states dont agree on the definition of person-centered care. Yet person-centered care is a core component of the dual eligible demonstration projects around the country. Says Chernof, a former general practitioner: As a physician, I think its very important there be a plan of care that integrates medical services and home- and community services and one thats built around a persons goals, not just medical problems.

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Medicares History: Key Takeaways

Discussion about a national health insurance system for Americans goes all the way back to the days of President Teddy Roosevelt, whose platform included health insurance when he ran for president in 1912. But the idea for a national health plan didnt gain steam until it was pushed by U.S. President Harry S Truman.

Covering Home Modifications And Mental Health

Two more areas where The SCAN Foundation thinks the patchwork Medicare/Medicaid system could be improved: helping dual eligibles stay in their own homes rather than be forced to move into nursing homes and addressing their behavioral health issues.

CMS should better define opportunities, incentives and parameters for health plans to provide non-covered services, like home modifications and certain medical equipment, The SCAN Foundation report says. Right now, Medicare Advantage plans, the alternatives to original Medicare sold by private health insurers, require that supplemental benefits be primarily health-related and have strict limits on coverage for things like home-delivered meals and minor home modifications.

Yet The Bipartisan Policy Center report noted that a home modification such as a railing installation or widening of a doorway might cost just $6 per month per Medicare eligible enrollee per year. We spend a lot of money inefficiently in health care, where a little help for someone to live at home is better for the person, said Chernof.

A CMS framework for states and health plans to develop systems integrating behavioral health services for a seamless care experience is hugely important, Chernof noted. The acute medical care world and the behavioral health world still work too much in isolation. A lack of coordination is a primary driver of poor outcomes and inefficient use of services.

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The Problem: Medicare Alone Will Cost You Money

Medicare is a great health insurance program, but it does have costs. You must pay your monthly Part B premium to stay enrolled in Medicare, plus premiums, out-of-pocket costs, etc. Copayments for medical services and prescriptions can add up beyond what many people can afford.

You could even wind up paying more than other folks for the same basic Medicare coverage, simply because extra coverage add-ons are out of reach.

Disadvantages Of Medicare Advantage Plans

Problems With Medicare Fraud, Medicaid and Social Security Part 2

In general, Medicare Advantage Plans do not offer the same level of choice as a Medicare plus Medigap combination. Most plans require you to go to their network of doctors and health providers. Since Medicare Advantage Plans cant pick their customers , they discourage people who are sick by the way they structure their copays and deductibles.

Although Mom saw her MA premiums increase significantly over the years, she didnt have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer medically necessary.

Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it custodial.

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Unrealized Intention Unpredicted Results

Medicaid was intended to improve health care access for the poor. It has yielded substantial benefits. There were approximately 23.5 million Medicaid recipients in 1989, about 16 million adult family heads and dependent children, and 8 million aged, blind, and disabled. . Those who have participated in the program have certainly benefited, as demonstrated by dramatic increases in utilization and improved health status in the period immediately following Medicaid’s enactment, particularly when compared with the poor without coverage .

However, Medicaid was never designed to serve everyone who is poor, nor to meet all health care needs of those eligible. Generally, Medicaid eligibility is linkedand limitedto the categorical groups and income levels defined for the cash assistance programs with limited exceptions, the standard of poverty for Medicaid is not the Federal poverty level. And, beyond a core set of mandatory, essential services, each State has, and has exercised, considerable discretion in offering additional types of health services to its Medicaid-eligible population.


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