Health Law and Regulation-Medicaid and Medicare
Mathew V Kurian
HCS/545
November 5 2012
Pro. Maureen Lancellot

Health Law and Regulation-Medicare and Medicaid
Medicare and Medicaid, created by the Social Security Amendment Act 1965, added Title XVIII and XIX to the Social Security Act. President Lyndon B Johnson was responsible for bringing about this change. Social Security Program started during the Great Depression of 1930s because of the stock market crash and bank failure, which wiped away the retirement savings of the Americans. Poverty rate among senior citizen exceeded 50% during this time. Social Security Act was created in an attempt to limit the five dangers of modern American Society. The Social Security Act was signed by President Franklin D Roosevelt on August 14, 1935, thus becoming the first president to advocate federal assistance to the elderly. Edwin Witt, the executive director of the president committee on economic security is the father of Social Security. If the total benefit paid by social security in 1940 was $35 million, it was $247.8 billion in 1990, after 50 years. In 2009, about 51 million Americans received $650 billion benefits, under different social security programs like social security disability insurance (SSDI), supplemental security income (SSI), retirement insurance benefits (RIB), temporary assistance for the needy families, ticket to work and self-sufficiency program, unemployment benefit, State children’s health insurance program, and Medicare and Medicaid.
Medicare
Title XVIII of the Social Security Act deals with Medicare. It is the country’s health insurance program for the people aged 65 or above. Certain younger people also will qualify for this program, including those who have certain disabilities, kidney failure, and amyotrophic lateral sclerosis (Lou Gehrig’s disease). Medicare does not cover all the medical expenses or the cost of most of long term-care. Medicare is financed by the payroll tax deduction from the employees, and the proportionate payment of the employer, and the deduction made of the social security checks. Center for Medicare and Medicaid Services manages the fund for the Social Security Administration. Medicare operates thorough four plans. Plan A deals with Hospital insurance and pays for inpatient care in a hospital or skilled nursing-facility, following a hospital stay and some home health care and hospice care. Plan B deals with Medical insurance. It pays for doctor’s services and many other medical services and supplies that do not come under plan A. Plan C deals with Medical advantage. Persons with plan A and Plan B can choose to receive all their health care services through the provider organizers under plan C. Plan D is the Prescription drug coverage which helps pay for medications doctors prescribe for treatment (Social Security Administration, U. S., July 2012). Eligibility and Benefits Most people aged 65 or older who qualify the conditions stated before and those who receive or are eligible to receive social security, railroad retirement benefit or their spouse is eligible or either of them have worked long enough in a government job where Medicare tax were paid, and those dependent parent of a fully insured child, are also eligible to receive Medicare.
If the person does not qualify for Medicare, that person can purchase it during the designated period, provided that person completes 65 years old. If the full retirement age is no longer 65, the person who needs Medicare can get it by signing up three months prior to that person’s 65th birthday.
Before the age of 65, a person is eligible for free Medicare hospital insurance if the person has been entitled to social security disability benefit for 24 months; The person receives a disability pension from the railroad retirement board; If the person is receiving social security disability benefit because of Lou Gehrig’s disease or has permanent kidney failure, and the person is receiving maintenance dialysis or a kidney transplantation; Or the person is the child or widow aged 50 years or older, including a divorced widow or of someone who has worked long enough in a governmental job where Medicare Taxes were paid. With respect to plan B, any person who is eligible for plan A can enroll in plan B by paying a monthly premium. The person not eligible for plan A or plan B can still buy plan B, if that person is more than 65 years old, and a citizen or legal resident. Persons who have plan A and B are eligible for plane C. Plan C include Medicare managed care plan. Medicare preferred provider (PPO) organization plan; Medicare private fee-for-service plan, and Medicare specialty service. Plan D is available to all the persons who have any of the other three plans, but need to pay a monthly premium.
Enrollment
The effective date of enrollment is January 1 of the up-coming year with right to make changes from October 15 to December seven each year. From the time a person becomes eligible, a seven months period is given for enrollment, starting from three months prior to 65th birthday. A delay will cause delay in coverage and higher premium. For plan B, the person has another chance each year to sign up during general enrollment time from January one to march 31. Person leaving Plan C insurance has an extended time to join plan D coverage. The rules for people covered under an employer group health plan are different.
Medicaid
Title XIX of the Social Security Act deals with Medicaid. It is a state run program, whereas Center for Medicare and Medicaid Services (CMS) monitors this program and establishes requirements for service delivery, quality, funding, and eligibility standards (Wikipedia, January 2012). It is a health program for the U.S. Citizens or legal permanent residents with low income and resources, their families, children, and people with certain disabilities. Poverty alone may not qualify someone for Medicaid. It is means tested program that is jointly funded by the state and federal government and is managed by the state. Medicaid is the largest source of funding for medical and health related services for people with limited income in the United States of America.
Different Population for Medicaid Center for Medicare and Medicaid Service serve the need of different population of this country (Centers for Medicare and Medicaid Services, January 2012) set different standards for different population to qualify to receive the benefits, and distinguish different type of beneficial service in accordance with the need of each population. Each state run Medicaid Program to suit the special need of that state by making appropriate changes to the guide-lines provided by CMS so that more people get the benefit of this program under each of the population. It is important to note that unless there is compliance with the mandatory requirement, the state shall not receive the Federal Matching Funds. The Five different populations under this program are children population, individual without disabilities population, pregnant woman population, individual-with disabilities population, seniors, and Medicare, and Medicaid-enrollees population.
Eligibility and Benefits of Medicaid to the populations Children. Minimum of above 100% of the FPL are eligible for Medicaid. All states have expanded coverage to children with higher income through CHIP. Today, children whose parents have an income of 240% or above the FPL are eligible for CHIP and Families with income up to $44,700/ year, for a family of four in 2011, are eligible for Medicaid or CHIP coverage. The benefits that the children in the program get is Early, Periodic Screening, and Diagnosis and Treatment (EPSDT) Non-disabled Adults. Only if an adult’s income averages 41% or less of the FPL, he or she is entitled to Medicaid. However, affordable care Act provides eligibility for most low- income adults with effect from 2014, if his or her income is above 133% of FPL ($14,500 in 2011) ns other eligibility group. Many states have already brought this change into effect.
Pregnant woman with income up to or over 185% of FPL are eligible for Medicaid. In some states women can spend down to eligibility, if their health care expenses are high. Once eligible, the pregnant woman remain eligible for Medicaid until the end of the Calendar month in which the 60th day after the end of the pregnancy falls and any change in her family income has no effect on the benefit. The benefits are Care related to pregnancy, Labor, delivery, and any complications during pregnancy, and prenatal care for 60 days. Individual-with-Disability. Individuals who qualify for Medicaid also qualify for SSI. In many states, SSI eligibility is accepted as the eligibility criterion for Medicaid. Some states are more restrictive, and they are known as 209(b) states. To qualify, the individual must succeed to prove that there is an impairment that stops the person from engaging in a “substantial gainful activity” at least one year. Once a determination is made, an asset test and specific income requirement needs to be considered as a candidate for Medicaid. Once selected, the individual gets all services deemed medically necessary. Almost all of the beneficiaries receive long-term services and support through various delivery systems. Seniors and Medicare and Medicaid Enrollees. Medicaid provides health coverage to 4.6 million low-income seniors, provides coverage to 3.7 million seniors with disabilities. They are also enrolled in Medicare. Thus 8.3 million seniors dually eligible for both Medicare and Medicaid constitute 17% of all Medicaid enrollees. By federal statute, they can be covered for both optional and mandatory categories. The benefits qualified Medicare Beneficiaries (QMB) has 100% FPL with $6,680/individual, $10,021/couple and Medicaid pays for part A and B premiums, deductible, co-insurance, and co-payment. Specified Low Income Medicare Beneficiaries (SLMB) has 120% FPL with $6,680/individual, $10,02/couple and the Medicaid
Pays for part B premiums only. Qualified individual (QI) and Qualified disabled working individual (QDW) has 135% and 200% FPL with $6,680 and $4,000/respectively for individual and $10,620/and $6,000/respectively for couple and Medicaid pays only for part B and part a premium respectively (Medicaid. Gov., July 2012).
Conclusion
According to the statistics available, 31 million children, including half of all low-income-children in the U. S., and 11 million non-elderly low-income parents; 8.8 million non-elderly persons with disabilities get the benefit of Medicaid. 4.6 million low-income seniors and 3.7 million seniors with disabilities, thus a total of 8.3 million seniors, enrolled in Medicare get the benefits of the Medicaid. Forty percent of all births in the United States is financed by Medicaid and it plays a vital role in improving the health of the child and mother in this country. As of 2008, there are 44 million Medicare enrollees; the cost of the program as of 2007 is $432/billion. Medicaid, on the other hand, is a social protection program with 40 million enrollees with a cost of about $330/billion in 2007. Together, Medicare, and Medicaid represent 21% of the FY 2007, U.S. Government (Medical News Today, January 2012).

References

Centers for Medicare and Medicaid Services, .. (January 2012). Keeping America Healthy. Retrieved from http://http://www.medicaid.gov
Medicaid. Gov. (July 2012). Seniors and Medicare and Medicaid Enrollees. Retrieved from http://http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Population/Medicare-Medicaid-Enrollees-Dual-Eligibles/Seniors-and-Medicare-and-Medicaid-Enrollees.html
Medical News Today, .. (January 2012). Medicare and Medicaid. Retrieved from http://http://www.medicalnewstoday.com/info/medicare-medicaid/
Social Security Administration, U. S. (July 2012). Medicare. Retrieved from http://http://www.socialsecurity.gov/pubs/10043.html
Wikipedia, (January 2012). Medicaid. Retrieved from http://http://en.wikipedia.org/wiki/Medicaid