Exam 2 Flashcards
1
Q
Who does medicare cover?
A
coverage for elderly, disabled, and end-stage renal disease (ESRD)
2
Q
What percentage of the total federal spending is spent on medicare?
A
15%
3
Q
Who is medicare administered by?
A
federal government
4
Q
When was medicare originally established?
A
1965
5
Q
when did medicare expand to cover disabled and ESRD as well as the elderly?
A
1972
6
Q
What does medicare part A cover?
A
inpatient hospital care (Room and board, nursing services)
skilled nursing facility, home health services, and hospice care
7
Q
When is the initial enrollment period for part A?
A
3 months - 65 - 3 months
8
Q
are there premiums in part A?
A
most beneficiaries do not pay monthly premiums
9
Q
is there an out-of-pocket maximum for part A?
A
No
10
Q
cost-sharing for part A…
A
- part A deductible
- coinsurance
11
Q
What does Medicare part B cover?
A
- doctor’s services, x-rays, lab tests, home health services, preventive care services, durable medical equipment
- some prescription drugs
12
Q
initial enrollment for part B?
A
3 months - 65 - 3 months
13
Q
are there premiums in part B?
A
monthly premium of $134 - $428 in 2018
14
Q
is there an out-of-pocket maximum for part B?
A
No
15
Q
cost-sharing for part B…
A
- part b deductible
- coinsurance (typically 20%)
- waived for most covered preventive care services
16
Q
examples of services not covered by medicare:
A
- hearing aids
- eye examinations related to prescribing glasses
- eyeglasses/contact lenses
- dental - cleanings, fillings, tooth extractions, dentures
- long-term care
17
Q
medicare supplement insurance is also known as…
A
Medigap policy
18
Q
what does medicare supplement insurance help pay?
A
helps pay Medicare Part A and Part B cost-sharing
- does not cover hearing aids, eyeglasses, dental care, long-term care
19
Q
what parts must you have to enroll in a medicare supplement insurance?
A
must have Part A and Part B
20
Q
is there a premium for medicare supplement insurance?
A
beneficiaries pay monthly premiums
21
Q
what does Medicare part D cover?
A
- outpatient prescription drugs
- does not cover over-the-counter drugs
22
Q
vaccines are covered by part B when…
A
if directly related to treatment of an injury or direct exposure to a disease or condition
23
Q
vaccines are covered by part D when….
A
in absence of injury or direct exposure (ex. preventive vaccination) ex. shingles
24
Q
when is hepatitis B vaccine covered by part B?
A
for beneficiaries at high or medium risk of contracting hepatitis B
25
when is hepatitis B vaccine covered by part D?
for beneficiaries at low risk of contracting hepatitis B
26
immunosuppressant drugs following kidney transplant covered by part B if....
- enrolled in part A at time of transplant
- transplant met Medicare coverage criteria
- enrolled in part B when drugs dispensed
27
immunosuppressant drugs following kidney transplant covered by part D if....
- not enrolled in part A at time of transplant
28
Do medicare beneficiaries choose their part D plan?
yes -- plans differ by covered drugs, cost-sharing, and pharmacies
- choice of plan depends where you live (regions) -- regions include 1 or more states
29
to enroll in part D you must...
be enrolled in part A OR part B
30
initial enrollment period for part D
3 months - 65 - 3 months
31
what/when is the open enrollment period for part D?
- can join, switch plans, or leave a plan
| - October 15 - December 7
32
what is unique to part D?
- initial coverage limit
- coverage gap/doughnut hole
- catastrophic coverage threshold
- catastrophic coverage
33
is there an out-of-pocket maximum for part D?
no
34
cost-sharing for part D...
- deductible
| - copayment and/or coinsurance
35
What is medicaid?
a public health insurance for low income individuals
36
who administers medicaid?
state administers the program but must follow federal guidelines
37
is state participation in medicaid voluntary?
yes - but all states have participated since 1982
38
what does medicaid being an entitlement program mean?
states must cover all individuals who meet the eligibility criteria and enroll
- poses a challenge when the economy is bad
39
what are the two different managed care organization Iowans can choose from currently?
Amerigroup and UnitedHealthCare
| - starting in July 2019 = Iowa Total Care
40
how is medicaid funded?
jointly by the federal and state governments via an open-ended matching program
41
what is the percentage of costs paid by the federal government called?
FMAP - federal medical assistance percentage
- varies by states but is currently 50-76%
- some services and populations have higher FMAPs
42
who wasn't eligible for medicaid pre-ACA?
childless adults and undocumented immigrants
43
when did the ACA begin?
January 1, 2014
44
what categorical eligibility was eliminated due to the ACA?
childless adults <65 years old would be eligible for the first time
45
who was still ineligible for medicaid under the ACA?
undocumented immigrants
46
the ACA increased the eligibility for children 6-18 and adults (parents/disabled) <65 to what?
133% of the FPL
47
when was the Affordable Care Act signed into law?
2010
48
what were the pre-ACA limited assets?
- most states had eliminated asset limits for children and pregnant women
- some states had eliminated asset limits for parents
- asset limits in place for elderly and disabled
49
what are the limited assets that came from the ACA?
- prohibited asset limits for children, parents, pregnant women, and childless adults
- asset limits for elderly and some disabled still allowed
50
what did the supreme court rule was unconstitutional for the ACA medicaid program?
unconstitutional for the federal government to withhold funds for the state's existing medicaid program if it did not proceed with the expansion
51
what became optional for state medicaid programs because of the supreme court ruling?
- increased eligibility for adults <65 years old to 133% of FPL (OPTIONAL)
- childless adults <65 years old would be eligible for the first time (<133% of FPL --- OPTIONAL)
52
what was mandatory of the state medicaid programs from the supreme court ruling?
- increased eligibility for children 6-18 years old to 133% of FPL (can be more, just NOT less)
- pregnant women 133% FPL
53
Iowa medicaid expansion premiums are waived if...
- complete health risk assessment
| - get wellness exam or dental exam
54
Iowa medicaid monthly premiums (ACA):
- <50% FPL = $0
- 50-100% FPL = $5
- 101-133% FPL = $10
55
in expansion states, what is available to low income adults age 19-64 not eligible for medicaid?
- if earn <400% FPL, qualify for premium subsidies (Assistance) to purchase insurance through the ACA marketplace
- employer based insurance, if offered and eligible
56
in non-expansion states, what is available to low income adults age 19-64 not eligible for medicaid?
- employer based insurance, if offered and eligible
- if earn 100-400% of FPL, qualify for premium subsidies to purchase insurance through the ACA marketplace
- if earn less than 100% FPL, do NOT qualify for premium subsidies to purchase insurance through the ACA marketplace -- coverage gap
57
what are the goals of state medicaid programs?
- controlling total health care costs
| - while maintaining access to health care services for their vulnerable populations
58
who can be enrolled in both medicaid and medicare - "dual eligible"?
low income:
- elderly
- disabled
59
what acts as the supplement coverage for dual eligibles?
medicaid acts as the supplement
- medicaid provides coverage for services that are not covered by Medicare (custodial nursing home care) and covers costs not covered by Medicare (medicare premiums and cost-sharing)
60
Part D and dual eligibles:
- are required to enroll in medicare part D
- are not responsible for part D premiums or deductibles (for certain plans)
- are responsible for part D copayments
- have part D out-of-pocket maximum (medicare beneficiaries usually do not have this)
61
what is CHIP?
Children's Health Insurance Program
62
CHIP background...
- established by the balanced budget act of 1997
| - expand public health insurance for children
63
what is different about CHIP and medicaid?
- federal funds are capped for each state for CHIP but not for medicaid
64
how does CHIP get financed?
- states administer the program (participation is voluntary)
- receive federal funds for the program but must follow federal guidelines to get those funds
- states must contribute their own funds toward the program in addition to federal funds
- federal matching rate is higher for CHIP than for medicaid
- federal funds are capped for each state. each state receives a yearly allotment
65
what can states do with the CHIP funding?
states can use the CHIP funds to expand medicaid eligibility (CHIP-funded medicaid expansion), create a separate CHIP, or both
66
Separate CHIP
- states have flexibility in choosing services to cover in a separate CHIP, but there are some services they must cover (child well care)
- state may use premiums and cost-sharing in a separate CHIP
- a separate CHIP is NOT an entitlement program like medicaid and therefore states may cap enrollment and have waiting lists
67
what is the separate CHIP in Iowa called?
Healthy and Well Kids in Iowa (Hawk-i)
68
how are hawk-i children covered?
- premiums depends on family income
| - coverage through one of the two medicaid managed care organizations
69
does CHIP need to be reauthorized periodically?
yes
70
what does VHA stand for?
veterans health administration
71
what is the VHA?
- provides health care benefits for veterans
- largest health care system in the US
- composed of medical centers, community-based outpatient clinics, and other facilities
- employs physicians, PAs, NPs, nurses, pharmacists, etc.
72
VHA eligibility?
- served in active military, naval, or air service
- cannot be dishonorably discharged
- meet minimum duty requirements
73
service-connected disability
veteran applied for and was granted a disability rating for a condition that developed or was exacerbated while in the military
74
higher spending on prescriptions translates to what?
higher premiums
75
formulary defintion
a listing of drug products that are covered under an insurance plan
76
drugs on a formulary are often categorized into what?
tiers
77
health insurers are very UNLIKELY to pay for hospital stays by which method?
per service
78
how does medicare usually pay for hospital stays?
per episode
79
physicians are typically paid per what?
per service
80
third party payers
a business - providing some kind of service/good (want to be profitable, but also want to satisfy their costumers because there is competition with the other many insurance companies)
81
will the penalty for delay enrollment in part B end?
no - not as long as you are still enrolled in part B and AMOUNT depends on how long after the initial enrollment period the beneficiary enrolled
82
will the penalty for delay enrollment in part A end?
yes - will not last forever and DURATION depends on how long after the initial enrollment period the beneficiary enrolled
83
doughnut hole in part D:
- beneficiary is responsible for 100% of the cost (pay until you reach the catastrophic coverage threshold)
- to help reduce the expenses that Medicare spends, they had to implement the doughnut hole
84
is there an out-of-pocket maximum for beneficiaries in Medicare Advantage for part A and part B?
yes there is
85
what are the medicare advantage premiums?
- pay the monthly part B premium
| - pay an extra monthly premium charged by medicare advantage plan (Depends on plan chosen)
86
what must you be enrolled in to enroll in medicare advantage?
part A AND part B
87
when is the open enrollment period for medicare part D?
October 15 to December 7
88
when is the open enrollment period for medicare advantage?
October 15 to December 7
89
what is the majority of Medicaid expenditures for?
acute care
90
what public insurance helps pay for long-term care (nursing home care)?
medicaid does
| medicare does not
91
what does open-ended matching for medicaid mean?
there is no cap on what the federal government will pay
92
what group of people were not affected by the ACA?
the elderly
93
medicare part D are more worried about what when it comes to assigning tiers?
cost of the drugs (don't have to worry about the long-term value of the drug as much)
94
assignment to tiers can be based on what?
cost of the drug (less expensive drugs are assigned to lower tiers)
value of the drug (more valuable drugs are assigned to lower tiers)
95
specialty drugs
- high cost
- difficult to administer
- requires special handling
- requires ongoing clinical monitoring
- usually is injectable drugs but growing for oral drugs as well
96
specialty drugs insurance coverage/tier
- may see a formulary tier composed solely of specialty drugs (with cost-sharing specific to that tier)
- speciality drugs may be covered under the medical benefit or the drug benefit
- if covered under drug benefit, may use same drug utilization management strategies used with traditional drugs
97
what is a PBM?
- pharmacy benefit manager -- a organization that provides administrative and other services associated with processing prescription drug claims and managing a pharmacy benefit
- NOT an insurance company
- hired by health insurance companies and self-funded employers
98
rebates
are payments made by pharmaceutical manufacturers in exchange for favorable placement of their products on formularies
99
purpose for formularies
- garner rebates
- encourage selection of more cost-effective drug over less cost-effective drug
- encourage selection of a drug with a better safety profile
100
how does an insurer get a pharmacy to accept even lower reimbursements?
offer pharmacy inclusion in the preferred pharmacy network
101
overview of PBM services
- processing of prescription drug claims
- drug utilization management
- pharmacy network management
- rebate negotiation
102
PBM market is dominated by which 3 firms?
- express scripts (Stand-alone PBM)
- CVS/caremark (ownership by pharmacy chains -- CVS purchased Caremark)
- OptumRx (ownership by insurance companies -- UnitedHealth)
103
historically PBMs were owned by what?
pharmaceutical manufacturers (not anymore)
104
current PBM revenue
- administration fees
- "spread" differences
- rebates from pharmaceutical manufacturers
105
PBM pricing "spread"
- difference between what the PBM pays the pharmacy and what the PBM charges the client for the same prescription
106
purpose of cost-sharing
- encourage patients to purchase drugs they value and intend to use
- reduce costs to insurer of purchasing drugs
107
days supply limitations purpose
control the amount of medication that can be obtained at one fill
108
quantity limits purpose
control how much of a medication will be reimbursed for a given number of days of therapy
109
prior authorization purpose
criteria that have to be met before an insurer will pay for a drug
- cover the drug for certain individuals
110
step therapy purpose
failure on one drug before insurer will pay for the desired drug
- cover the drug for certain individuals
111
prospective drug utilization review purpose
make adjustments to medication prior to dispensing
112
medication therapy management purpose
maximize safety and effectiveness of drug therapy
113
exceptions to drug utilization management tools purpose
formulary exception
| tier exception
114
experience rating
a person's premium is based on their own expected costs (Ex. people in poor health or with more health risk factors pay higher premiums than healthier people
115
pure community rating
a person's premium is based on the average expected claims in their geographic area. Premiums are not based on health status so sicker people pay the same premiums as healthier people
116
modified community rating
allow premium variation on selected characteristics that are related to health (Ex. smoking status), but restrict premium variation based explicitly on health status
117
who pays for employer-based insurance?
- employer pays large share
- employee pays some too
- federal / state government (tax subsidies)
118
pure community rating is mostly used in what insurance program?
Medicare and Medicare part D
119
what is the biggest concern in pure community rating?
adverse selection --
| healthy people leaving the pool
120
Under ERISA (a federal regulation)...
self-insured plans avoid state insurance regulation
121
self-funded plan
employer is the insurance company (they pay all the healthcare costs of their employees) ex. U of I (LARGE employers)
122
premiums vary across employers and depend on things such as:
comprehensiveness of coverage, health care costs in the area, and health status of the employees
123
employees costs for health insurance is increasing faster than what?
their earnings
| Deductibles increasing the most
124
is there a higher dollar subsidy for family coverage or single coverage?
much higher dollar subsidy for family coverage
125
Why would the government subsidize the purchase of health care?
- The prices are going up so much for everybody – want people to be insured
- It would lessen the adverse selection problem (healthy people would be more likely to stay in the market)
- Negative externalities – more ER visits from people who cannot afford care (which are very expensive)
...People might not get treatment for contagious diseases so it would spread to everybody
126
What is our current system for employer-based insurance like for subsidies?
everybody gets a subsidy (more income = more subsidy)
127
What is the ACA market like for subsidies?
only low income get subsidies
128
the government spends almost the same amount on subsidies for Medicaid/CHIP as it does for employer based insurance coverage T/F??
true
129
what groups of workers will be most affected by the "Cadillac" tax?
- Employers with a lot of older, sicker workers would have higher premiums
- Occupations with a high risk of injuries
- Employers that have a difficulty hiring people – need the incentive
- Auto-workers (union workers) – have very comprehensive & generous coverage plans (more expensive)
130
"cadillac" tax
beginning in 2022, 40% excise tax on employer health insurance premiums above a designated threshold
(Everybody above this threshold will have to pay this tax)
131
what employers struggle to offer health insurance?
small employers and employers with many low wage workers (McDonalds, Walmart)
132
what is the ACA "mandate" for larger employers?
"shared responsibility" requirement where employers with 50 or more employees must pay a penalty if they fail to offer full time employees affordable, comprehensive coverage
(largest effect is on the 50-100 employee firms and on firms with many low wage workers)
133
why was the "mandate" included in the ACA?
Primarily didn’t want employers to be dumping the sicker employees on the self-insured market (exchange net)
134
what are the "big 6" regulations for employer AND individual plans?
1. guaranteed issue
2. dependents can stay on parents' insurance plan until age 26
3. no pre-existing condition coverage exclusions
4. free preventive care for all new plans ex. BC (not for grandfathered plans)
5. out of pocket maximums
6. no lifetime maximum and elimination of annual limits (not for grandfathered plans)
135
ACA effect on small employers (less than 50 employees)
- not subject to employer insurance mandate, but must follow the "big 6" new insurance regulations
- change from experience rating (in most states) to modified community rating
- creation of state level exchanges (marketplaces)
- some small employers receive subsidies to help them purchase insurance
136
what is individual health insurance?
- insurance purchased directly from an insurer and not obtained through an employer or public program (can be single or family coverage)
- the ACA increased the number of people with individual insurance
137
ACA effects on the individual insurance market:
- Created American health benefit exchanges (insurance marketplaces)
- Insurance may be purchased through the exchange or off the exchange, but premium and cost-sharing subsidies ONLY available through the exchanges.
- Insurance exchanges are a way to present information to consumers, organize the sale of insurance, and encourage competition.
138
In the ACA, the states set rules for the exchanges under federal guidelines:
- Federal government runs the exchanges if states opt not to create the exchanges.
- Most states unwilling to or incapable of running their own exchanges.
- Some rules for insurance sold on the exchanges were in the ACA, but others were determined by at a later date. There have been many rule changes in the last two years.
139
ACA Rules for all New Individual Health Insurance Plans:
- Modified community rating where premiums may only vary by age (1 : 3), geographic area, tobacco use (1 : 1.5), and number of family members.
- All new plans must cover essential health benefits.
- Specified coverage tiers.
- Minimum loss ratio. Plans must spend at least 80% of premiums on health care costs and quality improvement.
- Also must follow Big 6 insurance rules.
140
New insurance policies sold on and off the exchanges must follow same rules. Why does this matter?
If the market isn’t regulated, the experience rating will always dominate (healthy, young people will buy this because it is based on your health status) and modified community rating would fail
141
Essential health benefits defined in the ACA law.
10 categories of essential benefits. Of note, maternity care, mental health services, and prescription drugs are considered essential.
142
Why have list of essential benefits?
- Knew there was an adverse selection problem
| - Makes it easier to comparison shop when all the plans have to cover these main buckets
143
Who wanted a more specific list of essential benefits?
Physicians – they wanted their work to be covered/paid for too
144
Catastrophic plans
high deductible health plans (only available for people under the age of 30)
145
Does same actuarial value mean that the plans are the same?
NO
146
if you are generally a sick person what type of insurance plan would you want?
low deductible plan (low out-of-pocket maximum plan)
147
what is the premium tax credit based on?
based on the cost of the second lowest cost silver plan in the area, so the amount of tax credit varies geographically
148
Pros of Medicare advantage:
Out of pocket maximums for A and B services
Likely covers more services than original Medicare (hearing, dental, vision)
Only dealing with one plan (simplicity)
Choice of plans
149
Cons of Medicare Advantage:
More limited choice of providers
Chance there may not be network providers where you go to get treatment
Complexity of comparing (differ on many aspects)
Not steady, reliable like traditional Medicare providers can move in and out of network in Medicare Advantage
150
If manufacturer wants its drugs covered by state Medicaid programs it has to what?
it has to participate in the rebate program
In exchange, states must generally cover all drugs made by participating manufacturers
(Applies to brand and generic manufacturers)
151
the formulary for medicaid is determined by what?
by manufacturer participation
152
how many tiers are on the medicaid PDL?
2 tiers - preferred and non-preferred drugs
| non-preferred drugs require PAs
153
If a manufacturer wants its drugs to be preferred drugs, it has to offer what? (medicaid PDL)
it has to offer supplemental rebates (above and beyond federally mandated rebates)
Why Medicaid populations get brand name drugs over generic drugs (it costs the state less because of the rebates)
154
cost-sharing for prescription drugs is allowed for who in medicaid?
adults
155
medicare part D formularies
- Each Medicare Part D plan maintains its own formulary
- Tiered formularies with tiered cost-sharing are allowed
- Medicare Part D plans are allowed to negotiate rebates from pharmaceutical manufacturers.
156
what is public health?
what we as a society do collectively to assure the conditions in which people can be healthy (physical, mental, and social well-being)
157
medical model vs. public health model
medical model: services provided to an individual (one person)
public health model: services provided to a population (many people)
158
what are the 3 core functions of public health?
assessment, policy development, and assurance
159
assessment of public health
- assessment of health status and health needs
| - Systematically collect, analyze, and make available information on healthy communities
160
policy development of public health
Promote the use of a scientific knowledge base in policy and decision making
161
assurance in public health
- Ensure provision of services to those in need
| - assurance that necessary services are provided
162
macro-level public health
- Planning level
- Emphasize the assessment and prioritization of a community’s health-related needs as well as planning to address those needs.
- Example: working with community representatives in identifying health-related community problems
163
micro-level public health
- Implementation level
- All the activities required to implement public health initiatives. Many of these services are performed on a provider-to-patient or a program-to-population basis, usually with a specific health-related outcome in mind.
- Example: disease screening
164
primary prevention
- Prevents an illness or injury from occurring at all, by preventing exposure to risk factors
- Reducing the actual incidence and occurrence of diseases, injuries, and disability
165
secondary prevention
- Seeks to minimize the severity of the illness or the damage due to an injury-causing event once the event has occurred.
- Decreasing the severity or progression of the disease, injury, and disability
166
tertiary prevention
- Seeks to minimize disability by providing medical care and rehabilitation services.
- Treatment or rehabilitation to return the disease, injury, or disability to the initial or baseline state
167
What is the impact of the decision not to pay the cost-sharing subsidies?
- Under the ACA, the cost-sharing subsidies must be given to eligible individuals, so they still get them.
- Insurers now must pay for the subsidies out of the money they collect for premiums.
- Insurers increased premiums to compensate.
- “Silver loading” was common.
- People who were not eligible for cost-sharing subsidies were often better off switching to a non-silver plan.
- Ironically, the federal government still pays the cost of the cost-sharing subsidies indirectly because they pay premium subsidies and the cost-sharing subsidies are now factored into the premiums.
168
results of "silver loading"
- Some gold plans had lower premiums than silver plans, even though they have a higher actuarial value.
- Since premium subsidy amounts are based on the cost of the second lowest silver plan, the average premium subsidy amount increased.
- Could’ve cost the government less to keep paying for the cost-sharing subsidies instead of the premium subsidies
169
what are consequences of the repeal of the individual mandate?
- it will affect the individual health insurance market the most (premiums will go up for individual private insurance)
- Healthy people not eligible for subsidies would most likely drop out
170
What are problems Mr. Lang is facing?
- He chose to be uninsured because he was relatively healthy and made a good amount of money
- He missed the open enrollment period
- He is in the coverage gap so he is unavailable for subsidies
- He is under 100% FPL (he is in a non-expansion state) so not eligible for Medicaid in his state
- If he goes blind he would be eligible for Medicare and disability insurance
- 2 year waiting process for disability insurance and a long process
171
what is working in the ACA?
- Number of uninsured is at an all-time low.
- The process for purchasing individual health insurance is much simpler.
- Possible for people in poor health to get health insurance.
- Less uncompensated care for hospitals, particularly in states that expanded Medicaid.
- Some improvement in the availability of affordable, comprehensive health insurance for low wage workers.
172
what is not working under the ACA?
- Still have very high health care costs.
- Coverage gap in states that did not expand Medicaid.
- Still have ~10% of the population that is uninsured.
- Individual health insurance market still has significant problems.
- Large premium increases.
- Especially problematic for people who are not eligible for premium subsidies.
- Narrow network plans.
- Large deductibles create access problems for some patients.
- Insurers leaving the exchange markets.
- Changing rules create market instability.
