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3 - Public Healthcare Financing Flashcards

1
Q

Who pays the MOST for health care?

3.3 trillion TOTAL

A

PRIVATE HEALTH INSURANCE (35%)

Medicare gray hair (21%)

Medicaid not paid (18%)

Out of pocket

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2
Q

Medicare

A

Gray Hair

Social security act of 1965

Entitilement program that provides insurance for:

ELDERLY PERSONS

Individuals with long term or perminant DISABILITY

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3
Q

Who does MEDICARE cover?

57.1 million enrolyees

A

Elderly 65>

Disabled persons <65
previously working / contribute to Social Security
SSDI (social security disability insurance) for >24 months

ESRD (end stage renal disease)

ALS (amyotrophic lateral Sclerosis = lou gherigs)

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4
Q

Medicare enrollment TRENDS

A

INCREASING OVER TIME

in 1975 = start covering nonelderly disabled people

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5
Q

CHARACTERISTICS of the Medicare Population

A

3+ CHRONIC Conditions = 65%

Income <23.5k = 50%

Savings <61.4k = 50%

Cog/mental impairment = 31%

Fair/Poor health = 27%

Etc

Long-term care / facility resident = 5%

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6
Q

4 parts of MediCARE

A

Part A = HOSPITAL INSURANCE = HI

Part B = Supplementary Medical Insurance = SMI

Part C = Medicare Advantage Program = MA

Part D = Outpatient RX DRUG BENEFIT

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7
Q

What does Part B cover?

A

Hospital Insurance

Covers INPATIENT care,

  • *short-term** stays in SNFs (skilled nursing facilities)
  • *hospice care** / post acute home health care / blood

Benes pay (2018):

  • no premium for nearly everyone*
  • *DEDUCTABLE = $1,340** per episode of illness (benefit period) for hospitilization
  • *$0** for other services
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8
Q

What do Benes Pay for Medicare PART A

A

no premium for nearly everyone

Deductable = $1340 per epidose of illness for hospitilization

$0 for other services

Copayment = NONE for days 1-60 of hospital stay
335$/day for 61-90 & 670/day for days 91+

for SNF = skilled nursing facilities, 1-20 = free -> $167/day 21-100

small for hospice / 20% for DME / none for home health

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9
Q

What does PART B cover?

A

Supplementary Medical Insurance, OPTIONAL

OUTPATIENT hospital care

Physician Visits

Ambulance

Labs / Medical Equipment / Diagnostic Tests

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10
Q

What do benes pay?

Part B

A

supplementary medical insurance –> outpatient / physician visits

Premium = $134/month (standard)
is higher for those with gross income >$85,000 per individual
is lower for those with Social Security benefits

Deductible = $183 per year

Copayments / coinsurance, after deductible is met
= 20% of medicare approved amount for services

0$ for home health + clinical labs

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11
Q

What is NOT covered under Original (A + B) Medicare plans?

A

Outpatient Prescription Drugs (with a few exceptions)

Deductibles / coinsurance / copayments

dental care / dentures

routine foot (orthopedic shoes) / eye care (most eyeglasses)

cosmetic surgery / hearing aids / exams

SCREENING TESTS / VACCINATIONS / Physical Exams

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12
Q

What do MediGAP Plans Cover?

A

Need to have Both A + B to have mediGAP
Fills in what is NOT covered by parts A+B

MOST COVER:
Part A deductible / SNF co-insurance / Foreign Travel emergencies

  • Some Cover*:
  • *Part B deductible + excess charges / Preventative care + @home**
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13
Q

What is a MEDIGAP PLAN?

A

Supplemental Policy sold by private insurance companies to fill gaps in the OG medicare plan coverage

10 standardized plan options ( A -> N)

Need to have Both A + B to have mediGAP
Fills in what is NOT covered by parts A+B

  • *only 20%>** of medicare benes had medigap in 2018
  • *54% had Plan F** (MOST COSTLY, covers Deductibles and excess charges))
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14
Q

What do Benes PAY?

for MediGAP Plans

A
  • *Monthly premiums** that depend on:
  • *Health / age / location / plan**

Estimated annual cost range from 8250 -> 8490 in our area

Plans A-N all VARY

most common is Plan F (54% of the 20% that get medigap)
MOST EXPENSIVE

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15
Q

What is the Medicare Part C Plan?

Was a way for people to get PRESCRIPTION COVERAGE before Med D came along​

A

Medicare Advantage Program (MA)
MANAGED CARE PLANS
run by PRIVATE companies = HMO / PPO / etc

Give access to physicials + other providers that are often limited to those in network

Inclusions of extra benefits + lower cost-sharing requirements than traditional medicare:
RX Drugs / Dental / Physicals / Vison / Health+Wellness

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16
Q

Trend of enrollment for

Medicare Advantage plans = Part C

A

Slight dip in 2000s

Normall Increased over time

Most PART C enrolees are in HMO’s

varies across states

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17
Q

What is the MEDICARE PART D plan?

A

Outpatient PRESCRIPTION drug benefit
estabilised as part of Medicare Modernization act of 2003 –> 2006

Delivered through Private plans that contract w/ medicare
coverage / premiums VARY by plan

Bene’s enroll in either private or Medicare Advantage (C)

PREMIUM varies by plan and by yearly income

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18
Q

Prescription Drug Plans

PDPs

PART D

A

PRIVATE stand-alone plans that offer RX drug coverage ONLY

25% REDUCTION in # of plans since 2015

Average of the 10 most popular Part D stand-alone PDPs:

Premium = 20-84$

(add drug coverate to original medicare)

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19
Q

Medicare Advantage RX Drug Plans

MA-PDs

A

Drug coverage that is integrated with the health coverage provided by the private managed care plan

(HMOs + regional PPOs)

20
Q

Standard Medicare Prescription Drug Benefit 2018

21
Q

PART D Plan

Drug Coverage

Must wait until next open enrollment period to SWITCH part D plans

Oct 15 - Dec 7

A

LARGE VARIABILITY
amoungst each PDP in what drugs are covered
not every plan covers the same drugs

May NOT pay to enroll if a person spend
<$800 per year on RX drugs
(average cost of the premium + deductible)
@ risk for UNEXPECTED need for meds

22
Q
A

Need to SHIFT the spending

Need to PREVENT / KEEP OUT OF HOSPITAL

medicare advantage is better

24
Q

Affordable Care Act

in MEDICARE

A

PART D benefit
FIllin in donut hair -> provide discount for brand name drugs in GAPS

Physician Reimbursement
10% bonus payment for PCP’s

Patient Cost-Sharing
Elminates Cost sharing for services recommended by US preventative services tast force

ACOs

Readmision Reducation Program

25
**What is MedicAID?**
**Aid the Not Paid** Social Security act of 1965 -\> for **limited income & assets** **_JOINT STATE & FEDERAL PROGRAM_** Eligibility **varies by the state**, *within federal rules*
26
**WHO is covered by MedicAID?**
**All Adults \<138% FPL** (federal poverty line) **Before ACA**, Medicaid only covered SPECIFIC categories of *low income individuals + other groups:* Children + Pregnant Women Parents of dependnt children + Individuals w/ disabilities + Age 65+
27
**Medicaid Enrollment WAS declining** now is back up **SENSITIVE TO _GVMT SPENDING & ECONOMY HEALTH_**
28
**Medicaid SPENDING is MOST with the DISABLED** **Enrollment is highest with Children + Adults**
29
**ACA's Impact on** **MedicAID's Expansion**
LARGE Increase in MedicAID **Enrollment** *reductions in **_uninsured rates_*** **Coverage gains in specific populations: Young adults / HIV / Parents / mothers / Children / Rural area** Expension positively impacts **acess to care** Improvements in **self-reported health**
30
**How did the ACA help fill in the donut hole?** in PART D Benefit
**Require** **manufactururers to provide** **DISCOUNT (50%) for brand name drugs filled in coverage gap** Donut hole = **gap/space where patients paid a large % of the drug price**
31
**How did the ACA regulate ACO's?** Accountable Care Organizations
**Required them to meet** **_QUALITY THRESHOLDS_** to share in the cost savings they achieve for the medicare program _***3 of 4 ACOs*** ***did NOT meet these thresholds for Bonuses***_
32
**ACA's Readmission Reduction Program**
**Hospitilized were PENALIZED if there was** **HIGH READMISSIONS** **for select conditions**
33
**MANDATORY** Covered services under **Medicaid**
*Pre-ACA Mandatory Sevices:* In/Out **Hospital Services** **Physicial + midwife / NP services** **Ea**rly / periodic diagnosing + screening + treatment f**or children** **Labs + Xrays** **Family Planning** non-emergency transportation
34
***_OPTIONAL_*** Covered services under medicaid
**_OUTPATIENT PRESCRIPTION DRUGS_** Physical + occupational therapy Podiatrist / optometrist / chiropracors / psychologist **dental care / medical eqt** **Hospice care / community care**
35
**How is Medicaid** **FINANCED?**
**State income Tax** **Federal Matching:** Formula based on state per capita income Ranges between 50% - 74%, IL = 51.3% **FEDERAL Income Tax** **Premiums + Cost Sharing** Sliding scales, TOTAL charges \<5% of family income Cost sharing up to 10-20%, dependent on income level
36
**What is CHIP?**
**Childrens Health Insurance Program** Largest expansion of health insurance - 1997 - 2009 **35.7 million** enrolled **State Administered: 3 OPTIONS:** **Medicaid Expansion** **Seperate Program** + COMBINATION OF 2 APPROACHES
37
**Who is Covered by CHIP?**
Targeted **LOW-INCOME _children \<19y/o & pregnant women_** States have flexibility to determine eligibility level Federal matching is LIMITED to families w/ incomes \<300% FPL **ACA impacts on Medicaid ALSO influence CHIP programs**
38
**What BENEFITS does CHIP Cover?**
* *MIRRORS MEDICAID SERVICES** * if state opted to expand medicaid* **Well-Baby & Well-child care + immunization + emergency services + dental care** **_Varies by STATE_**
39
**DIfferences between** **Medicare / Medicaid / CHIP**
**MediCARE is FEDERAL ONLY** eligibility + benefits are **UNIFORM** **_MedicAID + CHIP_** are **50 SEPERATE INSURANCE PROGRAMS** vary from **State To State** *more uniform now after ACA*
40
**OTHER GOVERNMENT FINANCING** US GVMT Provides healthcare o eligible beneficiaryies in other venues such as:
**Federal Bureau of PRISONS** **U.S Department of DEFENSE** **INDIAN health service** ***_STATES_*** may provide **other healthcare financing mechanisms**
41
**ACA** **Patient Protection & Affordable Care Act of 2010** GOALS
**2010 = AKA OBAMACARE** **Many provisions 2010 -\> 2017** ***_DECREASE_*** **number of UNINSURED / UNDERINSURED**
42
**2010 Provisions of** ACA Patient Protection & Affordable Care Act of 2010
* Review of health plan premium increases * Comparative **effectiveness research** * **Medicare beneficiary drug rebate** * Coordinating care for dual eligibles **•Generic biologic drugs** **•Pre-existing condition insurance plan** •Tax on indoor tanning services **_Adult dependent coverage to age 26_**
43
**2011 Provisions to the** ACA Patient Protection & Affordable Care Act of 2010
**_•Closing the Medicare drug coverage gap_** **•Medicare payments for primary care** * Medicare prevention benefits * Center for Medicare and Medicaid Innovation * Funding for health insurance exchanges * Medic**aid** payments for hospital-acquired infections
44
**2012 Provisions** ACA Patient Protection & Affordable Care Act of 2010
**•Accountable care organizations** in Medicare ***_•Reduce Medicare payments for hospital readmissions_***
45
**2013 Provisions** ACA Patient Protection & Affordable Care Act of 2010
•Medicaid payments for primary care **•Medicaid coverage of preventive services** **•Medicare tax increase** **_•Extension of CHIP_**
46
**2014 Provisions** ACA Patient Protection & Affordable Care Act of 2010
**_•Expand Medicaid coverage_** * Individual mandate * Health insurance exchanges **•Employer requirements** **•Medicare payments for hospital-acquired infections** **•No annual limits on coverage**
47
**2015 - 2017 Provisions** **ACA**
**INCREASE federal MATCH for CHIP** **TAX on high cost insurance**

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