Medicare とは？③

What about services that are not provided through Medicare?
Supplemental coverage for medical expenses and services that are not covered by Medicare are offered through MediGap plans. MediGap consists of 12 plans that the Centers for Medicare and Medicaid Services have authorized private companies to sell and administer. Since the availability of Medicare Part D, MediGap plans are no longer able to include drug coverage.
メディケアで支払われない補完的なサービスはメディギャップを通じて支払われる。メディギャップは認可された企業が販売・運営する12のプランからなる。メディケアDができたので薬剤は対象外。


Who is eligible for Medicare
To be eligible for Medicare, an individual must either be at least 65 years old, under 65 and disabled, or any age with End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant.)
メディケアの対象者は65歳以上、または65未満の障害者および透析が必要な末期肝臓病患者。

In addition, eligibility for Medicare requires that an individual is a U.S. citizen or permanent legal resident for 5 continuous years and is eligible for Social Security benefits with at least ten years of payments contributed into the system.
さらに、アメリカ市民で、5年連続で米国に居住し、10年以上社会保険料を支払っている必要がある。


Who pays for services provided by Medicare?
Payroll taxes collected through FICA (Federal Insurance Contributions Act) and Self-Employment Contribution Act are a primary component of Medicare funding. The tax is 2.9% of wages, usually half paid by the employee and half paid by the employer. Moneys are set aside in a trust fund that the government uses to reimburse doctors, hospitals, and private insurance companies. Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays.
給与税と自営業者拠出がメディケアの主な財源。給与の2.9％が税率で、通常は企業と従業員が折半して支払う。政府が医師、病院、民間保険会社に返金するための基金の積み立てる。その他に、保険料、控除免責金、共同保険、患者負担金なども財源となる。



http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicare とは？②

Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically necessary physician, outpatient hospital visit, home health care costs, and other services for aged and disabled. For example, Part B covers:
* Durable medical equipment (canes, walkers, scooters, wheelchairs, etc.)
* Physician and nursing services
* X-rays, laboratory and diagnostic tests
* Certain vaccinations
* Blood transfusions
* Rental dialysis
* Outpatient hospital procedures
* Some ambulance transportation
* Immunosuppressive drugs after organ transplants
* Chemotherapy
* Certain hormonal treatments
* Prothetic devices and eyeglasses.
メディケアパートBは、いわゆる補完的な保険（SMI）です。高齢者や障害者の医師、通院、在宅治療等の費用を保障します。具体的には、長く使う車いす等の器具代、医師への支払い、特定のワクチン、X線、輸血、透析機のレンタル、化学療法その他が含まれます。

Part B requires a monthly premium ($96.40 per month in 2009), and patients must meet an annual deductible ($135.00 in 2009) before coverage actually begins. Enrollment in Part B is voluntary.
パートBに加入する場合は、毎月保険料を支払います。免責金額もあります。パートBへの加入は任意です。

Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users to design a customer plan that can be more closely aligned with their medical needs. These plans enlist private insurance companies to provide some of the coverage, but details vary based on the program and eligibility of the patient. Some Advantage Plans team up with health maintenance organization (HMOs) or preferred provide organization (PPOs) to provide preventive health care or specialist services. Others focus on patients with special needs such as diabetes.
パートCはメディケア追加プランと呼ばれるもので、加入者が自分の病状に即して内容を変更することができます。民間保険会社が支払いの一部を負担しますが、詳細はプランや患者によって多様です。いくつかのプランは健康維持機関などと組んで予防的なサービスを提供します。また糖尿病などの特定のニーズに注目したものもあります。

In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D. Part D is administered by one of several private insurance companies, each offers a plan with different costs and lists of drugs that are covered. Participation in Plan D requires payment of a premium and a deductible. Pricing is designed so that 75% of prescription drug cost are covered by Medicare if you spend between $250 to $2,250 in a year. The next $2,850 spent on drugs is not covered, but then Medicare covers 95% of what is spent past $3,600.
2006年にメディケアは処方薬を範囲に含めるように拡張されました。パートDとして知られる部分です。パートDは民間保険会社によって運営され、各社によって提供する費用や薬が異なります。加入者は保険料の支払いと免責が必要で、費用は金額に応じて一定割合がメディケアから保障されるように設計されています。

http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicare とは？①

What is Medicare?
Medicare is a Federal health insurance program that pays for hospital and medical care for elderly and certain disabled Americans.
メディケアは政府の病院医療保険制度で、高齢者と特定の障害のあるアメリカ人を対象としています。

The program two main parts for hospital and medical insurance (Part A and Part B) and two additional parts that provide flexibility and prescription drugs (Part C and Part D).
メディケアは4つのパートから成り立っています。パートA・Bは病院と医療保険、パートC・Dは特異なケースへの対応と処方薬について記載されています。

Medicare Part A, or Hospital insurance (HI) helps pay for hospital stays, which means, supplies, testing, and a semi-private room. This part also pays for home health care such as physical, occupational, and speech therapy that is provided on a part-time basis and deemed medically necessary. Care in a skilled nursing facility as well as certain medical equipment for the aged and disabled such as walkers and wheelchairs are also covered by Part A. Part A is generally available without having to pay a monthly premium since payroll taxes are used to cover these costs.
パートA、またはHospital Insurance(HI)、は病院滞在の支払いを補助します。これには消耗品、診察、準個人部屋が含まれます。また、医学上必要とみなされる在宅治療や、介護施設での治療、車椅子などの高齢者・障害者に必要な医療器具についても記載されています。パートAは、給与税が財源に充てられているため、毎月の保険料を支払うことなく通常のサービスを受けることができます。

http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicaid とは？③

Who pays for services provided by Medicaid?
Medicaid does not pay money to individuals, but operates in a program that sends payments to health care providers. States make these payments based on a free-for service agreement or through prepayment arrangements such as health maintenance organizations (HMOs).
メディケイドは個人に現金が支払われるものではなく、州が医療提供者に医療費を支払う仕組みです。

Each State is then reimbursed for a share of their Medicaid expenditures from the Federal Government. This Federal Medical Assistance Percentage (FMAP) is determined each year and depends on the State's average per capita income level. Richer states receive a smaller share than poorer states, but by law the FMAP must be between 50% to 83%.
その後、各州は政府から償還を受けることができます。償還金額は年度毎に見直されます。裕福な州は少ない割合、貧しい州は多い割合の償還受けることができますが、割合は50%から83%の間でないといけないと法律で定められています。

States may impose nominal deductibles, coinsurance, or copayments on some Medical beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost sharing:
* Pregnant women,
* Children under age 18, and
* Hospital or nursing home patients who are expected to contribute most of their income to institutional care.
州は特定のサービスについて、メディケイドの受給者に一部負担を求めますが、妊婦、１８才未満の子供、所得の大部分が入院費で使われてしまう者、は一部負担の対象外となります。

All Medicaid beneficiaries must be exempt from copayments for emergency services and family planning services.
救急サービスは、家族計画サービスについては、全ての受給者が一部負担の対象外となります。

http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicaid とは？ ②

Who is eligible for Medicaid?
Each state sets its own Medicaid eligibility guidelines. The program is geared towards people with low incomes, but eligibility also depends on meeting other requirement based on age, pregnancy status, disability status, other assets, and citizenship.
各州がメディケイドの受給要件を決めます。低所得者に向けたプログラムですが、所得以外に年齢、妊娠、生涯、市民権等も要件に含まれます。

States must provide Medicaid services for individuals who fall under certain categories of need in order for the state to receive federal matching funds. For example, it is required to provide coverage to certain individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments. Other groups that the federal government considers "categorically needy" and who must be eligible for Medicaid include:
* Individuals who meet the requirements for Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996.
* Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL)
* Pregnant women with family income below 133% of the FPL
* Supplemental Security Income (SSI) recipients
* Recipients of adoption or foster care assistance under Title IV of the Social Security Act
* Special protected group such as individuals who lose cash assistance due to earnings from work or from increased Social Security benefits
* Children born after September 30, 1983 who are under age 19 and in families with incomes at or below the FPL
* Certain Medicaid beneficiaries
政府から助成を得るためには、州は特定のカテゴリに当てはまる個人にメディケイドを提供しなければならない。例えば政府から生活維持の給付を受けているとか、政府が必要と認めた場合です。他にも、政府の定める貧困レベル（FPL）との兼ね合いで決まる要件や、所得の少ない家庭の子供など。


States may also choose to provide Medicaid coverage to other similar groups that share some characteristics with the ones stated above but are more broadly defined. These include:
* Infants up to age 1 and pregnant women whose family income is not more than a state-determined percentage of the FPL
* Certain low-income and low-resource children under the age of 21
* Low-income institutionalized individuals
* Certain aged, blind, or disabled adults with incomes below the FPL
* Certain working-and-disabled persons with family income less than 250 percent of the FPL
* Some individuals infected with tuberculosis
* Certain uninsured or low-income women who are screened for breast or cervical cancer
* Certain "medically needy" persons, which allow States to extend Medicaid eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their state.
州は上記以外にも、上記に似た要件のグループに対してより広くメディケイドを適用できます。例えば、21才以下の低所得者、特定の年齢の障害者で所得がFPLを下回る者、結核患者などです。


Medicaid does not provide medical assistance for all poor persons. In fact, it is estimated that about 60% of America's poor are not covered by the program.
メディケイドは低所得者の補助が目的ですが、全員が受給できるわけではないです。試算では米国の低所得者の60％程度がプログラムの対象とされています。

http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicaid とは？ ①

What is Medicaid?
Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Primary oversight of the program is handled at the federal level, but each state:
* Establishes its own eligibility standards
* Determines the type, amount, duration, and scope of services
* Sets the rate of payment for services, and
* Administers its own Medicaid program.
メディケイドは所得審査のある、低所得者向けの医療サービスプログラムです。一義的には政府が管理しますが、各州が所得基準や給付金額、サービス内容等を定め、メディケイドを運営します。


What service are provided with Medicaid?
Although the States are the final deciders of what their Medicaid plans provide, there are some mandatory federal requirement that must be met by the States in order to receive federal matching funds. Required services include:
* Inpatient hospital services
* Outpatient hospital services
* Prenatal care
* Vaccines for children
* Physician services
* Nursing facility services for persons aged 21 or older
* Family planning services and supplies
* Rural health clinic services
* Home health care for persons eligible for skilled-nursing services
* Laboratory and x-ray services
* Pediatric and family nurse practioners services
* Nurse-midwife services
* Federally quailfied health-center(FQHC) services and ambulatory services
* Early and periodic screening, diagnostic, and treatment (EPSDT) for children under age 21
メディケイドの中身は州が最終的に決めますが、政府から補助を受けるにはいくつか要件があります。入退院、出産、子供へのワクチン、医師、２１才以上への看護施設など。

States may also provide optional services and still receive Federal matching funds. The most common of the 34 approved optional Medicaid services are:
* Diagnostic services
* Clinic services
* Intermediate care facilities for the mentally retarded (ICFs/MR)
* Prescribed drugs and prosthetic devices
* Optometrist services and eyeglasses
* Nursing facility services for children under age 21
* Transportation services
* Rehabilitation and physical therapy services
* Home and community-based care to certain person with chronic impairments
州は任意でサービスを追加することもできます。34種の認められたメディケイド任意サービスのうち主なものは以下です。診断、診療所、検眼と眼鏡、搬送、慢性機能障害への在宅・地域ケアなど。

http://www.medicalnewstoday.com/info/medicare-medicaid/

Medicaid and Medicare 入門

Medicaid and Medicare are two governmental programs that provide medical and health-related services to specific groups of people in the United States. Although the two programs are very different, they are both managed by the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.
メディケイド、メディケアはアメリカ政府機関 Health and Human Service 傘下のCMS（Centers for Medicare and Medicaid Services）が運営する医療関連のサービスです。

Medicare is a social insurance program that serves more than 44 million enrollees (as of 2008). The program costs about $432 billion, or 3.2% of GDP, in 2007. Medicaid is a social welfare (or social protection) program that serve about 40 million people (as of 2007) and costs about $330 billion, or 2.4% of GDP, in 2007. Together, Medicare and Medicaid represent 21% of the FY2007 U.S. federal government.
メディケアは社会保険で44万人が参加、メディケイドは社会福祉で40万人が参加しています。


Both Medicaid and Medicare were created when President Lyndon B. Johnson signed amendments to the Social Security Act on July 30,1965.
両者ともに、Lyndon B. Johnson大統領在任時の1965年に法制化されました。

http://www.medicalnewstoday.com/info/medicare-medicaid/