The Health Care Financing Administration

Both Medicare and Medicaid are administered through a division of Health and Human Services called the Centers for Medicare and Medicaid Services (CMS).

The United States (U.S) healthcare system is a large private system that consist of multiple payers, which leaves the U.S

The first characteristic of the US health care system is that there is no central governing agency which allows for little integration and coordination. While the government has a great influence on the health care system, the system is mostly controlled through private hands. The system is financed publically and privately creating a variety of payments and delivery unlike centrally controlled healthcare systems in other developed countries. The US system is more complex and less manageable than centrally controlled health care systems, which makes it more expensive. The second characteristic of the US health care system is that it is technology driven and focuses on acute care. With more usage of high technology,

The Centers for Medicare and Medicaid Services (CMS) website offer a variety of information on Medicare, Medicaid, and Chip. For information concerning Medicare this site offers you an abundance of information such as eligibility and enrollment, health plans, prescription drug coverage,

Since 1984, Medicare patients have been serviced under the prospective payment system of the Medicare program. Under this system, primary care providers are reimbursed for their services using a fixed payment for each patient that is determined by the patient’s diagnosis-related group at the time of the admission. Therefore, under the prospective payment system a hospital’s reimbursement is unaffected by the actual expenditures that are required to care for a patient.

The terminology (i.e., Federal health care programs) contains any program that provides medical benefits, even if directly, by means of insurance, that is paid directly, in full or in part, by the US Government (i.e., Through programs such as Medicare, Federal Employees Health Benefits Act, Federal Employees’ Compensation Act, the Longshore and Harbor Worker’s Compensation Act) or any State health plan (e.g., Medicaid, or a program receiving funds from block grants for social service plan requirements. Guidelines, an industry should have

Medicaid is a medical assistance program for low-income Americans. It is funded partially by the federal government and partially by the state and local governments. The federal government requires that certain services be provided and sets specific eligibility requirements. Medicaid covers the following benefits required by the federal government; early and periodic screening, diagnosis, and treatment services, rural health clinic services, family planning services, SNF and home health services for persons over 21 years old, physicians’ services, laboratory and x-ray services, outpatient hospital care, and inpatient hospital care. Because Medicaid is also partially run by the state and local government individual states sometimes cover services

Prior to The ACA, the United States was primarily composed of a private health care system. This meant that employers, families or individuals would buy health insurance through private insurance companies. There were also Medicare and Medicaid government insurance programs for qualifying individuals. (Bradey, 2016) Typically the Medicare program is reserved for those individuals who have reached retirement age and Medicaid is for the poor. There are exceptions to each of the programs that this paper will not explore.

The Medicaid program is jointly funded by the federal government and each individual state. To offset costs for struggling state budgets, the federal government will fully finance new enrollees in 2014, gradually reducing its contribution over time (Sederstrom, 2012). The federal government pays each state for a particular percentage of program expenditures. These expenditures are call the Federal Medical Assistance Percentage (FMAP). Per capita income, from each state, is one of the criteria that FMAP is based on. FMAP can range from 50%-75% based on the per capita incomes. Every 3 years, FMAPs are adjusted for each state to account for variations in the economy. Each state must ensure that they can fund their share of Medicaid expenses for the services and care available under their state plan. Generally, each state pays for services through managed care arrangements or fee-for-service arrangements. Each state can establish their own Medicaid provider payment rates, as long as they are within federal requirements. Under the managed care arrangements, each state has a contract with organizations to deliver care through networks and pay providers. Providers are paid on a monthly payment rate. Under a fee-for-service arrangement, each state pays providers directly for services. Payment rates may be based on the cost of providing the services, a percentage of what Medicare pays for services, and/or an assessment of what commercial

The U.S. health care delivery system is very complex because it is not a universal health system governed solely by the federal government. Only Americans with health care insurance coverage receive routine health services. Health insurance can be purchased in the private market or provided by the federal government. The uninsured and poor population acquire health insurance by government funded health care called Medicare and Medicaid. Medicare and Medicaid is the largest payer of health care services in the United States with Medicaid providing health services to about 72.5 million and Medicare provides health coverage to more than 55 million (CMS, 2015).

CMS is regulatory agency which works within the United States Department of Health and Human Services. It administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (SCHIP), and health insurance portability standards.

The United States currently employs a multipayer system. The payers in this system include the government and private insurance companies., thus the collection of money for health care is a joint responsibility of both parties. Private insurance companies collect premiums and other payments from enrolled individuals and businesses. The government collects taxes from individuals and businesses. Regarding reimbursement, the private insurance industry reimburses providers for health care services delivered to privately insured individuals, while the government reimburses providers for health care services delivered to publicly insured individuals (e.g. people enrolled in Medicare, Medicaid, S-CHIP, or the VA).

The three principle parties involved in the U.S. Healthcare system are the consumer, provider and insurer. The provider includes the hospitals, clinics, doctors, nurses and pharmacies that provides a service; the consumer is the individual who receives the medical service and supplies the money; and the insurer is a third party intermediary between the provider and the consumer which accept money from a pool of consumers and reimburse the providers. Like any transaction, there is a certain degree of risk associated for members of the different parties. This risk is based upon variables within the U.S. healthcare model including the method of, and who is reimbursing the providers.

The way that the private health insurance companies work is very complicated. The second payer that finances U.S healthcare system is the private health insurance, and it consists of employer-sponsored insurance and private non-group (individual market) (Ping Chua, 2006). The employer

Reimbursement is costs or repayment for health care benefits. In the United States health benefits are often provided before the payment is made. End result physicians, clinics, hospitals, and other health care contributor establishment request reimbursement for health services provided in addition to expenses incurred. Presently reimbursement of claims for healthcare service depends on the appointment of medical codes to explain the diagnosis.