PRESENTATION SLIDES



History

The battle for Medicare started with Harry Truman’s abortive attempt to enact national health insurance in 1948. In the early 1950s, Social Security officials realized that older Americans were facing a health care crisis. The Social Security system, which was created as an economic safety net for older Americans, was failing to protect them against the greatest single cause of economic dependency in old age–the high cost of medical care. Between 1950 and 1963, the aged population grew from about 12 million to 17.5 million, or from 8.1 to 9.4 percent of the U.S. population. At the same time, the cost of hospital care was rising at a rate of about 6.7 percent a year. In1960 when health care costs rose, it caused politicians to push through Congress legislation under which the federal government provided states 50 percent to 80 percent of the funds they spent on medical assistance for the poorest old people, which included hospital, surgical and physician care, drugs, and false teeth. By 1963 five big states ( New York, California, Massachusettes, Michigan, and Pennsylvania) with only 32 percent of the population were taking up 90 percent of the federal funds. In 1964 Lyndon B. Johnson made Medicare an overarching priority. In July 1965, the House and Senate passed the bill which established Medicare, a social insurance program designed to provide all older adults with comprehensive health care coverage at an affordable cost. In 1972, Medicare eligibility was extended to two other groups that were facing similar problems in obtaining reliable health coverage–people with disabilities and people with end-stage renal disease.



Overview

The centers for Medicare and Medicaid Services administers Medicare, the nation’s largest health insurance programs, which covers over 40 million Americans. If you are not a U.S. citizen or a lawfully admitted alien who has lived in the U.S. continuously for a five-year period, please contact the Social Security Administration at 1-800-772-1213 for your Medicare enrollment and eligibility.

What is Medicare?

Medicare is a two-part, federally funded program that offers health insurance to the elderly. Medicare also may cover those who have either had a kidney transplant or are being treated through kidney dialysis.

Part A:

Part A helps pay for necessary medical care and services given by Medicare-certified hospitals, skilled nursing facilities, home health agencies, and hospices. It does not cover doctor visits or prescription drugs.

• You can also call the Social Security Administration toll free at 1-800-772-1213 or call or visit your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

Part B:

Part B of Medicare helps pay for doctors, outpatient hospital care, ambulance transportation, and a variety of other tests and services.

• The Part B monthly premium in 2004 is $66.60. It is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months

• Please call the Social Security Administration at 1-800-772-1213 or visit or call your local Social Security office to sign up.

• If you did not take Part B when you were first eligible for Medicare, you may sign up during the General Enrollment Period. The General Enrollment Period runs from January 1 through March 31 of each year.

Although it seems as though Medicare covers almost everything it does not cover most outpatient prescription drugs, most nursing home care, eyeglasses (except after cataract surgery), dental care, hearing aids, health care outside of the United States and acupuncture.



If you have questions about your eligibility for Medicare Part A or Part B, or if you want to apply for Medicare, please call the Social Security Administration toll-free at 1-800-772-1213 or visit or call your local Social Security office. The TTY-TDD number for the hearing and speech impaired is 1-800-325-0778. You can also get information about buying Part A as well as Part B if you do not qualify for premium-free Part A.

Eligibility

In order to determine eligibility for Medicare you can refer to , which has links that will give you detailed information on your eligibility and enrollment.

• Part A also known as hospital insurance helps pay for care in a hospital and skilled nursing facility, home health care and hospice care.

a. You are eligible for Part A if you or your spouse has worked for at least 10 years in Medicare covered employment and you are 65 years old and a citizen or permanent resident of the United States

b. You are eligible to receive Part A at age 65 without having to pay premiums if you:

i. are already receiving retirement benefits from Social Security or the Railroad Retirement Board

ii. are eligible to receive Social Security or Railroad benefits but have not yet filed for them

iii. or your spouse had Medicare covered government employment

c. You are eligible to receive Part A under the age of 65 without having to pay premiums if you:

i. have received Social Security or Railroad Retirement Board Disability benefit for 24 months

ii. are a kidney dialysis or kidney transplant patient

• Some states also have programs that pay some or all of Medicare cost deductibles and premiums to qualify you must:

a. have part A

a. have assets, such as bank accounts, stocks , and bonds that are not more than $4,000 for a single person, or $6,000 for a couple

b. have a monthly income that is below certain limits

• Part B also known as Medical Insurance helps pay for doctors, outpatient hospital care and other medical services

c. All of the eligible candidates for Medicare must pay for Part B.

Demographics

A. Median Age

i. 1990 U.S. Census was 32.9

ii. 2000 U.S. Census was 35.3

B. Population between 45 and 54

i. Swelled 49% from 1990 to 2000 census

C. Population of 65 and older

i. 2000 census marked the first time in history that the 65 years and over population did not grow faster than the total population. The census illustrates that 35 million people were 65 years of age or older. This amounts to 12.4 percent of the U.S. population. In 1990 there was 3.8 million less and accounted for 12.6 percent of the population. The decline is said to be caused by low birth rates in the late 1920’s and early 1930’s. Experts explain that the trend is temporary, and is expected to reverse as the baby boomers(those born between 1946 and 1964) reach age 65 starting in 2011.

Options Under Medicare

A Medigap Insurance

B Medicare Select

C. Medicare+Choice

A. Medigap Insurance

* Definition

i. It is health insurance that private insurance companies sell to help cover the gaps in what the original Medicare Plan covers

ii. These policies pay most - if not all - of the costs for coinsurance and co-payments under the original Medicare Plan and may also cover the original Medicare Plan deductibles.

A. Medigap Policies

a. “A”-“J” Plans

i. The benefits covered by Medigap Plan A are the same regardless of which health insurance carrier is offering Plan A.

ii. Health insurance carriers may charge different prices for the same type of Medigap plan.

B. Medigap Policies

Medigap Benefit |A |B |C |D |E |F |G |H |I |J | |Part A Deductible |  |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |Part B Deductible |  |  |[pic] |  |  |[pic] |  |  |  |[pic] | |Part A and B Coinsurance |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |Part B Excess - Above Medicare's Approved Amount |  |  |  |  |  |[pic] |[pic] |  |  |[pic] | |Basic Drug Benefit ($1,250 Limit) |  |  |  |  |  |  |  |[pic] |[pic] |  | |Extended Drug Benefit ($3,000 Limit) |  |  |  |  |  |  |  |  |  |[pic] | |Foreign Travel Emergency |  |  |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |At-Home Recovery |  |  |  |[pic] |  |  |[pic] |  |[pic] |[pic] | |Skilled Nursing Coinsurance |  |  |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |Preventative Care |  |  |  |  |[pic] |  |  |  |  |[pic] | |365 Extra Days of Hospital Coverage |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |3 Pints of Blood |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |[pic] | |

C. Medigap Policies

a. For more information on Medigap and its policies, including what coverage each plan entails, click on one of the links below





D. Medicare Select

a. If you buy a Medicare SELECT policy, you are buying one of the 10 standardized Medigap plans, A through J.

b. The difference is with a Medicare SELECT policy, generally you must use specific hospitals to get full insurance benefits (except in an emergency)

i. The stipulation requires that you use their network of providers (doctors and hospitals) in order to receive full benefits if you are not covered at all hospitals, as you are with regular Medigap insurance.

c. For this reason, Medicare SELECT policies generally cost less.

i. If you don’t use a Medicare SELECT hospital for non-emergency services, you will have to pay what the original Medicare Plan doesn’t pay

ii. The original Medicare Plan will pay its share of approved charges no matter what hospital you choose.

d. For more information click on the link below



E. Health Maintenance Organizations (HMOs)

a. Under the HMO plan, Medicare+Choice HMOs must provide all Medicare-covered services and may provide benefits not covered by original Medicare.

b. For your care to be covered you must receive all your health care either from the HMO or from a provider the HMO refers you to.

i. The only exceptions are an emergency or an urgently needed care situation.

c. Exception

i. HMOs can offer a Point of Service (POS) option

1. Under the POS option, beneficiaries can go out of the network to receive services, but with higher out-of-pocket payment requirements.

2. Like Medicare HMOs, PPOs must offer all of Medicare’s required benefits.

a. They may also offer additional benefits, such as annual physicals, other preventive services, disease management, and prescription drug benefits

d. For more information click on the link below



F. Preferred Provider Organizations (PPO)

a. Like Medicare HMOs, PPOs must offer all of Medicare’s required benefits.

i. They may also offer additional benefits, such as annual physicals, other preventive services, disease management, and prescription drug benefits.

ii. Unlike HMOs, PPOs will provide some coverage for services provided outside of their network

1. Co-payments and deductibles will be lower when you use network providers than when you use out-of-network providers.

b. For more information click on one of the links below





G. Provider Sponsored Organizations (PSO)

a. PSOs also are like HMOs, except that they are formed by a group of hospitals and doctors who directly take on the financial risk of providing comprehensive health benefits for Medicare beneficiaries

i. There is no insurance company involved.

H. Private Fee-For-Service (PFFS)

a. Are indemnity-type insurance plans\

i. The insurance plan, not Medicare, determines how much to reimburse providers.

ii. Providers are allowed to bill beyond what the plan pays, up to a limit.

1. The beneficiary is responsible for paying whatever the plan doesn't cover and could also be responsible for additional premiums.

Medicare Modernization Act

This preserves and strengthens the current Medicare program, adds important new prescription drug and preventive benefits, and provides extra help to people with low incomes and you will still be able to choose doctors, hospitals and pharmacies.

cus/medicare/

Current Medical Conditions

Medicare is in big trouble as of late. It is now predicted to go bankrupt sooner than expected and the rise of prescription drug prices are not helping. The problems with Medicare are driving the Democrats to criticize Bush’s plan and John Kerry is getting the chance to show his ideas.



SSA Report

The Social Security Administration submits their report every year on the overall status of Medicare and what the future looks like for it. It shows the increase in the costs of prescription drugs and how the lower tax income with higher than anticipated expenditures.



Recommendations

1. On average, name brand prescription drugs in Canada cost an estimated 40% less than they do in the U.S.

a. So what is stopping us from buying from abroad…….the FDA

2. FDA

a. The U.S. forbids the import of prescription drugs by anyone other than the original U.S. manufacturer, and even then only when the drugs meet all the approval requirements of the FDA.

b. The FDA asserts that it is looking out for consumer safety, but in fact a growing number of prescription drugs sold in the U.S. are made overseas and brought in by domestic manufacturers.

i. Prescription drugs bought by Americans increasingly are produced in foreign countries with minimal FDA oversight and then shipped to the U.S.

ii. Seventeen of the 20 largest drug companies worldwide now make drugs in Ireland including Pfizer, producer of Lipitor-the largest selling drug in the world, and Viagra.

1. Other countries include Germany, France, Japan, and even Singapore

3. The FDA maintains that “consumers who buy prescription drugs from Canada are at risk of suffering adverse events, some of which can be life threatening.”

a. At a June 2003 hearing, members of Congress quizzed William Hubbard, the FDA’s associate commissioner on the issue.

i. When asked if he brought any evidence of adverse events that indicated people were harmed by Canadian drugs coming across the border, Hubbard answered, “We have very little evidence.”

b. Actually drug-safety regulation is often stricter overseas than in the U.S.

i. Case in point, in 2002, it was leaked out that a very successful drug, Serzone, had significant side effects

ii. Bristol-Myers then announced that it would stop selling the drug in the Netherlands and Sweden, and eventually withdrew it from all of Europe and Canada.

iii. The FDA’s only response to this development was to require a black-box warning on the label.

4. Our recommendation is to allow U.S. consumers to buy prescription drugs from overseas.

a. Prescription drugs in Canada are on average 40% less than here in the U.S.

i. The price of a typical prescription in the U.S. for Zocor, which is a cholesterol reducer, is $372 to $451

1. In Canada, that same prescription would cost a consumer $198 to $224, a savings of nearly 47%.

b. Allowing Americans to buy these same prescription drugs in Canada would not only save Americans money in the short term, but it would also force the prices of these drugs in America to fall to the level of what is seen overseas and reduce the out-of-pocket costs that consumers must pay.

5. Our second recommendation is to adjust the recent Medicare Modernization Act of 2003.

a. The bill bars the Department of Health and Human Services (HHS), which purchases drugs for some seniors under Medicare, from negotiating with drug companies to get better prices

i. Government auditors have repeatedly singled out Medicare for paying inflated prices compared with what HMOs and retail pharmacy chains pay for the same drugs.

1. In 2001, a HHS inspector general’s report said Medicare reimbursements for two dozen drugs “exceeded actual whole-sale price by $761 million a year.”

b. The Department of Veterans Affairs (VA) negotiates lower drug prices through its nationwide Pharmacy Benefits Management Program

i. A 2002 study by the General Accounting Office showed that the VA’s prices for some cholesterol drugs were more than 70% lower than retail prices for the same drugs

1. The VA’s largest savings come from deals that are made with big pharmaceutical companies with national contracts

ii. All in all, according to a 2001 investigation, the VA paid an average of 52% less for a list of two dozen drugs than did Medicare all because they were allowed to negotiate the price of their drugs.

c. Allowing Medicare to negotiate the price of drugs with the pharmaceutical companies would have the same effect and would save the program hundreds of millions of dollars.

If you would like any more information on this topic, TIME magazine ran an article on this issue in their February 2, 2004 issue.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download