EXTRA CREDIT -- CH 18 Medicare and Medicaid Flashcards

1
Q

true or false

medicare has had tremendous growth since its inception

A

true

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

as mentioned, there has been rapid growth in medicare beneficiaries since its expansion.

what does this lead to?

A

rapid growth in medicare program SPENDING

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what were the 2 largest individual components of total medicare expenditures in the 1960s?

what changed in 2010? what was the reason for this

A

inpatient hospital services and physician services in the 1960s

in 2010, it was inpatient hospital services and MANAGED CARE SERVICES – these were not even existent until the 90s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what is another word for medicare supplement insurance

A

MEDIGAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

is medigap (medicare supplemental insurance) the same as medicare part C?

A

NO

medicare part C INCLUDES part A and B as well as additional benefits

MEDIGAP is a SUPPLEMENT to the original parts A and B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

true or false

medicare does NOT pay for all of their beneficiaries health care bills.
it actually pays less than half of the average person’s expenses

A

true

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

as mentioned, the average medicare beneficiary has substantial cost-sharing requirements in the form of deductibles, premiums, coinsurance, copayments, etc

what is available to help these beneficiaries meet these cost sharing requirements?
(4 potential things)

A

-some patients may have additional retiree health insurance through a former employer/union

-might be poor enough to qualify for medicaid

-enroll in a medicare advantage plan that covers more services than traditional medicare (part C)

-can purchase additional private insurance known as MEDICARE SUPPLEMENT INSURANCE (medigap)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

______- insurance is designed to pay for many of the charges for medicare-covered services for which the benficiary is responsible

A

medicare supplement insurance (AKA medigap)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

explain how medigap policies are classified

A

in letters – A-N

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

which medigap policy is REQUIRED for each state to allow the sale of it in accordance with federal law? also, all Medigap insurers must offer this plan.

it is the most basic Medigap plan

A

Plan A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

how many “basic benefits” are in Plan A of Medigap? name them

A

5:
covers:
1. Part A coinsurance hospital costs up to an additional 365 days after medicare benefits have been used up

  1. Part B coinsurance or co-payment
  2. Part A hospice care coinsurance or co-payment
  3. 3-pint blood deductible
  4. Preventative Part B coinsurance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

explain other medigap plans (besides A)

A

other plans offer additional benefits on top of Plan A.
this could include covering Part A hospital deductible and part B deductible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

which 2 medigap plans include an annual LIMIT on beneficiaries’ out of pocket spending?

A

K and L
once the limit is reached, parts K and L pay 100% of covered services for the rest of the year

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

in addition to initiating the medicare program, the 1965 amendments to the Social Security Act established what other program?
it is called Title _____ of the social security act

A

MEDICAID
title 19 – “Grants to the states for medical assistance programs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what is the largest source of funding for the provision of health-related services to the United States’ poorest people?

A

MEDICAID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Medicare was originally a ____ on the medicare bill in 1965

A

RIDER

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

after _______’s election, movement towards a universal health plan stalled

A

Richard Nixon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

at the time, many people viewed the legislation that created medicare and medicaid as a ____ measure.
why?

A

STOPPGAP

people assumed a democrat like Lyndon Johnson or Hubert Humphrey would be elected in 1968 and universal health plan would be a reality soon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

3 broad groups of people may be covered by a state’s Medicaid program:

A

-the mandated categorically needy

-the optimally categorically needy

-the medically needy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

explain eligibility for medicaid.
does it vary state to state?

A

states establish their own criteria within federal guidelines – eligibility varies from state to state

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

_______ is a joint state-federal program

A

MEDICAID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Name the 3 groups who are classified as “medically categorically needy”

A

-low income families with children

-children under 6 and pregnant women whose family income is below 138% of Federal Poverty Line

-Children under age 19 in families whose income is below the FPL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

medicare-eligible individuals with incomes below the FPL and limited assets are known as….

what benefits do they receive?

A

qualified medicare beneficiaries

-medicaid must pay the premiums and other cost sharing expenses incurred with part A and B of medicare

24
Q

what law expanded medicaid coverage to ALL non-medicare eligible individuals under age 65 with incomes up to 133% below the FPL (at the time it was 133% , now it’s 138%)

A

patient protection and affordable caer act

25
Q

give some examples of “optionally catgeorically needy” groups.
how do their benefits work?

A

-children or pregnant women
-children under 21
-someone with tuberculosis

all determined by the state – may cover these groups only if they are more than 138% below the poverty line, or other conditions

26
Q

if a state program DOES include the optionally categorically needy in their medicaid services, what kind of benefits MUST the state provide?

A

the same Medicaid benefits as those provided to people in mandatory categories

27
Q

do state medicaid programs HAVE to cover the “medically needy” groups?

A

no

28
Q

who classifies as “medically needy”

A

they WOULD be eligible for medicaid under the other groups due to their condition, but their income and/or assets are higher than what is allowed by the state

they qualify if their MEDICAL EXPENSES reduce their net income to the medicaid eligibility due to high out of pocket costs

29
Q

medicaid is FUNDED by whom?

A

both federal and state governments

30
Q

true or false

federal and state governments share responsibility for administering medicaid

A

true

31
Q

how many different medicaid programs are there?

A

56
1 for each state, territory, and the district of columbia

32
Q

true or false

the federal government does NOT REQUIRE any state to have a medicaid progam

A

true

33
Q

medicaid is unlikely to provide care for poor individuals unless they are….

A

children, parents, pregnant, elderly, blind, or disabled

34
Q

only _____% of americans living in poverty are covered by medicaid

A

true – income is not the only factor

35
Q

the portion of medicaid program costs that is paid for by the federal government for provider services is known as……

A

FMAP (federal medical assistance percentage)

36
Q

how is each state’s FMAP determined

A

through a formular that compares the state’s average per capita income to the national average

37
Q

who has a smaller share of their medicaid costs paid for by the federal government – states with a high per capita income or low?

A

higher per capita states get paid less

38
Q

what was the American Recovery and Reinvestment Act of 2009

what was the tradeoff?

A

temporary change to FMAP

states were provided with an increase in Medicaid FMAP due to the recession at the time when the demand for medicaid services was high

in return, the states could not restrict eligibility further of make it more difficult for people to apply for medicaid benefits

39
Q

true or false

the total amount of money that the federal government spends on medicaid has a defined set limit

A

FALSE – no specific limit.
it matches state gov spending % ages.
the more the state spends, the more medicaid $ they get

40
Q

how do providers get paid for services delivered to medicaid patients?

A

the state program pays them directly

41
Q

what is balance billing?
is it allowed?

A

balance billing is when providers don’t get paid as much as they expected from Medicaid, and thus bill the patient for the amount they were expecting from Medicaid.

this is NOT ALLOWED

42
Q

What are the guidelines on Medicaid payments to providers?

A

-must be high enough to attract a lot of providers so that services are available to medicaid ppl

-medicaid payments for institutional services cannot exceed the amounts paid for by medicare

43
Q

outpatient prescription drug coverage is an optional or mandatory provision of medicaid?

A

OPTIONAL – federal gov does not require it, but all 50 states participat

44
Q

do most medicaid programs require recipients to pay deductibles, copayments, and premiums?

A

yes, but very small amounts

45
Q

for which services can cost sharing NOT be required under medicaid

A

emergency care
family planning
pregnancy related
children younger than 18

46
Q

between these 3 groups, who does medicaid spend the most and the least on?

-children
-elderly
-disabled

A

most on disabled, then elderly, then children

47
Q

which SERVICES contribute the most to medicaid expenses?

A

managed care
inpatient hospitals
nursing homes
home health care

48
Q

from the 70s — now, have medicaid expenditures increased or decreased for prescription drugs?

A

decreased – due to the addition of medicare part D in 2006

49
Q

what has been the GREATEST change in medicaid-expenses related to services

A

MANAGED CARE – was non existent in the 70s but now accounts for the largest chunk of expenses

50
Q

name 3 general requirements for medicaid programs, established by the federal government

A

statewideness – medicaid program must run across the entire state and services covered cannot differ across the state

freedom of choice– must be allowed to obtain covered services from any qualified participating provider

comparability of services – amount, duration, and scope of services must be equal for all persons whether they’re in the mandatory or optional categories

51
Q

what are the 2 waivers to medicaid general requirements

A

section 1115 and section 1915b

1115 – allow statewide demonstration projects aimed at covering additional uninsured individuals and testing new budget-neutral delivery systems

1915b – allows states to implement innovative delivery and reimbursement systems

52
Q

the 2 waivers mentioned were extremely important during what time period?

A

in allowing states to experiment with managed care options in the early 90s

53
Q

what was the balanced budget act of 1997

A

eliminated the need for states to request a waiver to implement Medicaid managed care programs

54
Q

true or false

there has been a tremendous growth in the number of medicaid beneficiaries who are enrolled in managed care programs

A

true

55
Q

explain how medicare and medicaid are philosophically different

A

medicare is a social insurance policy for which beneficiaries have paid through taxes

medicaid is based on a welfare concept of redistributing wealth

56
Q
A