EXTRA CREDIT -- CH 18 Medicare and Medicaid Flashcards
true or false
medicare has had tremendous growth since its inception
true
as mentioned, there has been rapid growth in medicare beneficiaries since its expansion.
what does this lead to?
rapid growth in medicare program SPENDING
what were the 2 largest individual components of total medicare expenditures in the 1960s?
what changed in 2010? what was the reason for this
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
what is another word for medicare supplement insurance
MEDIGAP
is medigap (medicare supplemental insurance) the same as medicare part C?
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
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
true
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)
-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)
______- insurance is designed to pay for many of the charges for medicare-covered services for which the benficiary is responsible
medicare supplement insurance (AKA medigap)
explain how medigap policies are classified
in letters – A-N
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
Plan A
how many “basic benefits” are in Plan A of Medigap? name them
5:
covers:
1. Part A coinsurance hospital costs up to an additional 365 days after medicare benefits have been used up
- Part B coinsurance or co-payment
- Part A hospice care coinsurance or co-payment
- 3-pint blood deductible
- Preventative Part B coinsurance
explain other medigap plans (besides A)
other plans offer additional benefits on top of Plan A.
this could include covering Part A hospital deductible and part B deductible
which 2 medigap plans include an annual LIMIT on beneficiaries’ out of pocket spending?
K and L
once the limit is reached, parts K and L pay 100% of covered services for the rest of the year
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
MEDICAID
title 19 – “Grants to the states for medical assistance programs
what is the largest source of funding for the provision of health-related services to the United States’ poorest people?
MEDICAID
Medicare was originally a ____ on the medicare bill in 1965
RIDER
after _______’s election, movement towards a universal health plan stalled
Richard Nixon
at the time, many people viewed the legislation that created medicare and medicaid as a ____ measure.
why?
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
3 broad groups of people may be covered by a state’s Medicaid program:
-the mandated categorically needy
-the optimally categorically needy
-the medically needy
explain eligibility for medicaid.
does it vary state to state?
states establish their own criteria within federal guidelines – eligibility varies from state to state
_______ is a joint state-federal program
MEDICAID
Name the 3 groups who are classified as “medically categorically needy”
-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
medicare-eligible individuals with incomes below the FPL and limited assets are known as….
what benefits do they receive?
qualified medicare beneficiaries
-medicaid must pay the premiums and other cost sharing expenses incurred with part A and B of medicare
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%)
patient protection and affordable caer act
give some examples of “optionally catgeorically needy” groups.
how do their benefits work?
-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
if a state program DOES include the optionally categorically needy in their medicaid services, what kind of benefits MUST the state provide?
the same Medicaid benefits as those provided to people in mandatory categories
do state medicaid programs HAVE to cover the “medically needy” groups?
no
who classifies as “medically needy”
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
medicaid is FUNDED by whom?
both federal and state governments
true or false
federal and state governments share responsibility for administering medicaid
true
how many different medicaid programs are there?
56
1 for each state, territory, and the district of columbia
true or false
the federal government does NOT REQUIRE any state to have a medicaid progam
true
medicaid is unlikely to provide care for poor individuals unless they are….
children, parents, pregnant, elderly, blind, or disabled
only _____% of americans living in poverty are covered by medicaid
true – income is not the only factor
the portion of medicaid program costs that is paid for by the federal government for provider services is known as……
FMAP (federal medical assistance percentage)
how is each state’s FMAP determined
through a formular that compares the state’s average per capita income to the national average
who has a smaller share of their medicaid costs paid for by the federal government – states with a high per capita income or low?
higher per capita states get paid less
what was the American Recovery and Reinvestment Act of 2009
what was the tradeoff?
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
true or false
the total amount of money that the federal government spends on medicaid has a defined set limit
FALSE – no specific limit.
it matches state gov spending % ages.
the more the state spends, the more medicaid $ they get
how do providers get paid for services delivered to medicaid patients?
the state program pays them directly
what is balance billing?
is it allowed?
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
What are the guidelines on Medicaid payments to providers?
-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
outpatient prescription drug coverage is an optional or mandatory provision of medicaid?
OPTIONAL – federal gov does not require it, but all 50 states participat
do most medicaid programs require recipients to pay deductibles, copayments, and premiums?
yes, but very small amounts
for which services can cost sharing NOT be required under medicaid
emergency care
family planning
pregnancy related
children younger than 18
between these 3 groups, who does medicaid spend the most and the least on?
-children
-elderly
-disabled
most on disabled, then elderly, then children
