The CAPC Payment Accelerator: A Joint Virtual Workshop for Home-Based Care Teams-CAPC Payment Quick Tips - Understanding Medicare Medicaid and Commercial

CAPC Payment Quick Tips - Understanding Medicare Medicaid and Commercial

Pdf Summary

Health care services in the U.S., including palliative care, are primarily funded by third-party payers such as commercial insurance, Medicaid, and Medicare. Here is a breakdown of how coverage is provided and key points for palliative care providers to consider:<br /><br />1. **Health Insurance in the U.S.**:<br />   - **Employer-Sponsored Insurance**: Covers 51% of the population; 60% are self-funded.<br />   - **Medicaid**: Covers 21% of the population; nearly half are children.<br />   - **Medicare**: Covers 16% of the population; primarily individuals over 65.<br />   - **Dual Eligible**: 21% of Medicare beneficiaries also qualify for Medicaid.<br /><br />2. **Medicare**:<br />   - Federal program covering individuals over 65, those with end-stage renal disease, or those receiving disability income for over two years.<br />   - Divided into four parts: <br />     - Part A: Inpatient, hospice, skilled nursing, and some home health care.<br />     - Part B: Outpatient services, supplies, and therapy.<br />     - Part C: Medicare Advantage, allowing for private plan enrollment.<br />     - Part D: Prescription drug coverage.<br /><br />3. **Medicaid**:<br />   - State-led program, often in partnership with federal government, covering those at 100-138% of the federal poverty level.<br />   - Generally offers more extensive long-term care services compared to Medicare.<br /><br />4. **Medicare Advantage (MA)**:<br />   - Private plans receiving monthly payments from Medicare to cover Part A and B benefits.<br />   - Includes the flexibility to offer supplemental benefits such as dental, hearing aids, and special benefits for the chronically ill.<br /><br />5. **Implications for Palliative Care**:<br />   - Privatization of Medicare and Medicaid presents opportunities for partnerships with private payers.<br />   - Providers must understand the differing lines of business to negotiate effectively for coverage modifications.<br />   - Importance of precise documentation for risk adjustment and revenue enhancement.<br /><br />Palliative care providers should work closely with billing and coding specialists to ensure accurate and comprehensive documentation, which is crucial for optimizing revenue and demonstrating value to payers. Additional resources are available to help providers navigate Medicare and Medicaid regulations and changes.

Keywords

Health Insurance

Palliative Care

Medicare

Medicaid

Employer-Sponsored Insurance

Medicare Advantage

Coverage

Third-Party Payers

Revenue Enhancement

Documentation