Exam 1 - Powerpoint 3

Question 1

Medicare Modernization Act

Answer 1

Passed in 2003, went into affect 2006 and introduced Part D drug benefit

Question 2

Part D essential Facts

Answer 2

70% Medicare enrollees enrolled
15-20% Medicare beneficiaries have other drug coverage
~12% Medicare beneficiaries no drug coverage

Question 3

Part D Market characteristics

Answer 3

Multiple buyers and sellers

Buyer decides

Question 4

Part D financed….

Answer 4

Mostly through general revenues ~78%, 13% premiums, 9% state payments

Question 5

Part D Sign up delay

Answer 5

If you delay, and don’t have “creditable” coverage, you pay 1% per month, for every month you delayed, forever

Question 6

Formulary

Answer 6

List of covered drugs

Question 7

Requirement for Prescription Drug Plan (PDP)

Answer 7

at least 2 drugs in each usP category and class
All or most of the following 6…
Antiretrovirls, antineoplastics, antidepressants, antipsychotics, anticonvulsives, immunosuppressants

Question 8

Prescription Drug Plan changes

Answer 8

New formulary can be changed each year before open enrollment (Oct 15 - Dec 7)

After March 1 of plan year, can only make changes if give MD 60+ day notice, current patients on drug get it for rest of year

Question 9

Plans cost management tools

Answer 9

Prior auth - doc document medical necessity
Quantity limits - cap on quantity/dose per month
Step therapy - must fail first on a preferred med
Tiers Low to High cost sharing - incentivize cheaper med

Question 10

Donut hole

Answer 10

A coverage gap, where patient pays 100% out of pocket until they hit catastrophic phase’

2011-2019 = slowly eliminated due to ACA
2020+ it doesn’t exist

Question 11

Part D premiums

Answer 11

Vary a lot, on network, competing plans, region, doctors, pharmacy networks

Question 12

Low Income Subsidy

Answer 12

Zero Part D premiums low or zero cost sharing

about 30% of Part D enrollees receive it

Question 13

Benchmark plans

Answer 13

Basic plans with sufficiently low premiums in each region, and then CMS/Medicare will pay entire premium.

If enrollee wants better plan, they pay the difference

Question 14

Part D Plans vary in

Answer 14

Premiums
Cost-sharing
Formulary
Utilization management

Question 15

Reasons for rising uninsurance

Answer 15

Fewer employers could afford to offer insurance to workers

Employers shifting high cost premiums onto workers

Plans and employers tried to slow rise of premiums by making insurance less generous (less cover or more cost sharing)

Workers decline coverage offered due to too expensive, not generous enough

Few people can afford own non-group plan

Premiums for employer-sponsored insurance growing much faster than wages or general inflation

High healthcare cost burden among lower income groups and the underinsured

Question 16

Externalities

Answer 16

seeing others problems and misery makes me suffer, altruism

Question 17

Job lock

Answer 17

workers afraid to change jobs fear of losing health insurance.

Mistmatch between workers and jobs, lower overall US productivity, weakens economy

Question 18

Who pays for uncompensated care

Answer 18

Hospital shift $$ from paid for patients to unpaid.

Gov takes taxes to help cover unpaid care,

We end up paying for it

Question 19

NeedyMeds

Answer 19

consolidator of websites, providing links to financial help to patients for drug access

Has prescription assistance programs (PAPs), state drug assistance, drug discount coupons

Question 20

Drug discount card

Answer 20

Cannot be used with insurance, can only use instead of insurance

up to 80% off of cost

Question 21

Industry-sponsored PAPs concerns

Answer 21

Copay assistance programs help patients, but they increase demand for high-cost medicines making patients insensitive to price, company charge more, insurance pay more, we pay the higher insurance costs

Question 22

Mass Healthcare reform

Answer 22

Guaranteed issue = cant turn anyone away
Community rating = based on demographic
Merge small group markets into one risk pool
The connector = marketplace

Question 23

Mass Individual mandate

Answer 23

all 18+ have to be covered
penalty for not insured
all college students have to have, 18-25 can stay on parents

Question 24

Mass shared responsibility, Government

Answer 24

Medicaid program = MassHealth enrollment caps removed

CHIP = Childern’s Health Insurance Program expanded

Question 25

Mass shared responsibility, Employers

Answer 25

mandates for moderate-large employers

Help for small businesses

Question 26

ACA Triple Aim

Answer 26

Improve the experience of care
improve the health of populations
Reduce per capita costs of health care