EXTRA CREDIT -- CH 18 Medicare and Medicaid

Question 1

true or false

medicare has had tremendous growth since its inception

Answer 1

true

Question 2

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

what does this lead to?

Answer 2

rapid growth in medicare program SPENDING

Question 3

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

what changed in 2010? what was the reason for this

Answer 3

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

Question 4

what is another word for medicare supplement insurance

Answer 4

MEDIGAP

Question 5

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

Answer 5

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

Question 6

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

Answer 6

true

Question 7

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)

Answer 7

-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)

Question 8

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

Answer 8

medicare supplement insurance (AKA medigap)

Question 9

explain how medigap policies are classified

Answer 9

in letters – A-N

Question 10

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

Answer 10

Plan A

Question 11

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

Answer 11

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

2. Part B coinsurance or co-payment
3. Part A hospice care coinsurance or co-payment
4. 3-pint blood deductible
5. Preventative Part B coinsurance

Question 12

explain other medigap plans (besides A)

Answer 12

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

Question 13

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

Answer 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

MEDICAID

Question 16

Medicare was originally a ____ on the medicare bill in 1965

Answer 16

RIDER

Question 17

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

Answer 17

Richard Nixon

Question 18

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

Answer 18

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

Question 19

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

Answer 19

-the mandated categorically needy

-the optimally categorically needy

-the medically needy

Question 20

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

Answer 20

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

Question 21

_______ is a joint state-federal program

Answer 21

MEDICAID

Question 22

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

Answer 22

-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

Question 23

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

what benefits do they receive?

Answer 23

qualified medicare beneficiaries

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

Question 24

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%)

Answer 24

patient protection and affordable caer act

Question 25

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

Answer 25

-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

Question 26

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

Answer 26

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

Question 27

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

Answer 27

no

Question 28

who classifies as "medically needy"

Answer 28

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

Question 29

medicaid is FUNDED by whom?

Answer 29

both federal and state governments

Question 30

true or false federal and state governments share responsibility for administering medicaid

Answer 30

true

Question 31

how many different medicaid programs are there?

Answer 31

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

Question 32

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

Answer 32

true

Question 33

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

Answer 33

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

Question 34

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

Answer 34

true -- income is not the only factor

Question 35

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

Answer 35

FMAP (federal medical assistance percentage)

Question 36

how is each state's FMAP determined

Answer 36

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

Question 37

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

Answer 37

higher per capita states get paid less

Question 38

what was the American Recovery and Reinvestment Act of 2009 what was the tradeoff?

Answer 38

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

Question 39

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

Answer 39

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

Question 40

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

Answer 40

the state program pays them directly

Question 41

what is balance billing? is it allowed?

Answer 41

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

Question 42

What are the guidelines on Medicaid payments to providers?

Answer 42

-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

Question 43

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

Answer 43

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

Question 44

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

Answer 44

yes, but very small amounts

Question 45

for which services can cost sharing NOT be required under medicaid

Answer 45

emergency care family planning pregnancy related children younger than 18

Question 46

between these 3 groups, who does medicaid spend the most and the least on? -children -elderly -disabled

Answer 46

most on disabled, then elderly, then children

Question 47

which SERVICES contribute the most to medicaid expenses?

Answer 47

managed care inpatient hospitals nursing homes home health care

Question 48

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

Answer 48

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

Question 49

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

Answer 49

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

Question 50

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

Answer 50

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

Question 51

what are the 2 waivers to medicaid general requirements

Answer 51

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

Question 52

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

Answer 52

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

Question 53

what was the balanced budget act of 1997

Answer 53

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

Question 54

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

Answer 54

true

Question 55

explain how medicare and medicaid are philosophically different

Answer 55

medicare is a social insurance policy for which beneficiaries have paid through taxes medicaid is based on a welfare concept of redistributing wealth