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PUSHES > 3 - Public Healthcare Financing > Flashcards

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

A
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

23
Q
A
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
Q

What is MedicAID?

A

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
Q

WHO is covered by MedicAID?

A

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
Q
A

Medicaid Enrollment WAS declining now is back up

SENSITIVE TO GVMT SPENDING & ECONOMY HEALTH

28
Q
A

Medicaid SPENDING is MOST with the DISABLED

Enrollment is highest with Children + Adults

29
Q

ACA’s Impact on

MedicAID’s Expansion

A

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
Q

How did the ACA help fill in the donut hole?

in PART D Benefit

A

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
Q

How did the ACA regulate ACO’s?

Accountable Care Organizations

A

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
Q

ACA’s Readmission Reduction Program

A

Hospitilized were PENALIZED if there was

HIGH READMISSIONS

for select conditions

33
Q

MANDATORY

Covered services under Medicaid

A

Pre-ACA Mandatory Sevices:
In/Out Hospital Services
Physicial + midwife / NP services

Early / periodic diagnosing + screening + treatment for children

Labs + Xrays

Family Planning

non-emergency transportation

34
Q

OPTIONAL

Covered services under medicaid

A

OUTPATIENT PRESCRIPTION DRUGS

Physical + occupational therapy

Podiatrist / optometrist / chiropracors / psychologist

dental care / medical eqt

Hospice care / community care

35
Q

How is Medicaid

FINANCED?

A

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
Q

What is CHIP?

A

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
Q

Who is Covered by CHIP?

A

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
Q

What BENEFITS does CHIP Cover?

A
  • *MIRRORS MEDICAID SERVICES**
  • if state opted to expand medicaid*

Well-Baby & Well-child care
+ immunization + emergency services + dental care

Varies by STATE

39
Q

DIfferences between

Medicare / Medicaid / CHIP

A

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
Q

OTHER GOVERNMENT FINANCING

US GVMT Provides healthcare o eligible beneficiaryies in other venues such as:

A

Federal Bureau of PRISONS

U.S Department of DEFENSE

INDIAN health service

STATES may provide other healthcare financing mechanisms

41
Q

ACA

Patient Protection & Affordable Care Act of 2010

GOALS

A

2010 = AKA OBAMACARE

Many provisions 2010 -> 2017

DECREASE number of UNINSURED / UNDERINSURED

42
Q

2010 Provisions of

ACA

Patient Protection & Affordable Care Act of 2010

A
  • 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
Q

2011 Provisions to the

ACA

Patient Protection & Affordable Care Act of 2010

A

•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
  • Medicaid payments for hospital-acquired infections
44
Q

2012 Provisions

ACA

Patient Protection & Affordable Care Act of 2010

A

•Accountable care organizations in Medicare

•Reduce Medicare payments for hospital readmissions

45
Q

2013 Provisions

ACA

Patient Protection & Affordable Care Act of 2010

A

•Medicaid payments for primary care

•Medicaid coverage of preventive services

•Medicare tax increase

•Extension of CHIP

46
Q

2014 Provisions

ACA

Patient Protection & Affordable Care Act of 2010

A

•Expand Medicaid coverage

  • Individual mandate
  • Health insurance exchanges

•Employer requirements

•Medicare payments for hospital-acquired infections

•No annual limits on coverage

47
Q

2015 - 2017 Provisions

ACA

A

INCREASE federal MATCH for CHIP

TAX on high cost insurance

PUSHES (20 decks)

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