Exam 1 - Powerpoint 2

Question 1

Classic economic market

Answer 1

Buyer has a budget
Multiple buyers and sellars
Easy entry and Exit for Sellars and Buyers
Good Information
Buyer Decides
Buyer pays the prices

Question 2

Health care in US characterized by

Answer 2

Excess and deprivation

Question 3

Ways to think of “excess”

Answer 3

seeing specialist when NP might’ve been enough

Taking expensive brand drug vs cheap generic

Question 4

Deductible

Answer 4

Amount you must pay for healthcare or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay

Question 5

Coinsurance

Answer 5

amount you may be required to pay as your share of the cost for services after you pay any deductible. Coinsurance is usually a percentage

Question 6

Copayment

Answer 6

Set amount, rather than a percentage. Example, you may $10 or $20 for a doctor visit or prescription, regardless of cost

Question 7

Value-based insurance plans

Answer 7

have different payment structure that varies the cost-sharing amount depending on the value of the service

great value = health benefit or “payoff” is high, and cost is low, ie very cost-effective services, ex hypertension meds provided for free to patient

Question 8

Medicare

Answer 8

Passed in 1965

All Americans over 65, and 10 yrs of FICA taxes

in 1972, added End Stage Renal Disease and Long term disabilities (2 yr waiting period)

2001 Added ALS
2018 covered about 60mil, 84% are 65+

Federal program, same benefit all states

Question 9

Medicare Part A

Answer 9

Hospital insurance, automatic w/ 10yr FICA

Hospital, skilled nursing care, home care related to hospitalization, hospice
No premium for almost all enrollees

Question 10

Medicare Part B

Answer 10

Medical insurance, provider coverage (voluntary)

Physician visits, outpatient services, preventive, home care
Physician admin drugs
required premium, vary by income but also subsidized

Question 11

Medicare Part C

Answer 11

Medicare Advantage

Managed care version of Medicare, covering A,B, and optionally D
Only through private plans, mostly HMOs and PPOs
Formerly known Medicare+Choice

Question 12

Medicare Part D

Answer 12

Outpatient drug coverage (voluntary)
Only through private plans
Requires premiums, vary by income and can be subsidized

Question 13

Supplements (Medicare)

Answer 13

Not part of medicare

Medigap private plans
Employer-sponsored employee + retiree benefits

Question 14

Medicare Part A Cost sharing

Answer 14

Days 1-60 Max $1408 OOP
Days 61-90 $352 per day OOP

After 90, can use up to 60 reserve days at $704 per day, then anything after that is all OOP. This if its all one visit

Question 15

Diagnosis-Related Groups

Answer 15

Phased in the early to mid 1980s
Pre-determined payment based on the reason for hospitalization
caused length of stays to drop
shifted patient surgeries from inpatient to outpatient

Question 16

How is Part A funded

Answer 16

Medicare portion of FICA payroll taxes, no premium

Question 17

How is Part B funded

Answer 17

Monthly premiums (~27%, rest from US Gov tax revenue)

Question 18

Fee schedule Part B

Answer 18

Defined fees for specific services

Question 19

Medicare Supplement plans

Answer 19

known as Medigap
beneficiaries pay the full premium
additional coverage, reduced cost sharing

Question 20

Retiree Health Benefits

Answer 20

Declining over time

Usually these are Medicare supplemental plans

Question 21

Medicare Advantage (Part C)

Answer 21

little or no additional premium (past part B)

plans receive a capitation from CMS = a per member per month amount

private plans with hospital/doctor networks.

enrollment in Medicare Advantage has nearly double in past decade

Question 22

Prescription Drug Plans (Part D)

Answer 22

Passed GW Bush 2003, into effect 2006

All private plans

Question 23

How is Part D funded

Answer 23

Mostly General revenue taxes and premiums

Question 24

Medicaid

Answer 24

enacted along with Medicare

Varies state, jointly financed by federal and state gov
Entitled eligible individuals to a defined set of benefits

Question 25

Medicaid Highlights

Answer 25

Federal share is about 60%

Wealthiest states pay up to 50% costs, poor states 25%

receive rebates reducing drug prices by ~45%

major source of coverage for low-income children and families

Supplemental coverage for poor Medicare Beneficiaries

Primary payer of longer term care - nursing home

Supports safety net hospitals

Question 26

Medicaid growth

Answer 26

Growth due to population growth, program expansions, erosion of other sources of coverage, and wage stagnation

Question 27

Medicaid Funds

Answer 27

Pulls federal funds to states

“automatic stabilizer” = money flows to states during economic downturn because poverty and eligibility increase

Question 28

Enrollee and Expenditure

Answer 28

Disabled ( 15% enrollee, 42% of costs)
Elderly (9% enrollee, 21% costs)
Adults (27% enrollee, 15% costs)
Children (48% enrollee, 21% costs)

Question 29

Dual Eligibles

Answer 29

dual enrollees

Have both medicare and medicaid coverage
are sicker compared to others on just in Medicaid and Medicare

Question 30

Medicaid Benefits

Answer 30

Mandatory Benefits
Hospital, outpatient/doc, birth and family planning, nursing home, home care, transportation, smoking cessation

Optional Benefits
Rx coverage, dental, case management, hospice

All states currently cover Rx

Question 31

Medicaid cost sharing

Answer 31

$0 premiums under 150% FPL

>150% FPL premiums possible bust must be <5% income