Healthcare Finance Flashcards
Most Common Types of Healthcare Coverage in US
- Employer Only Insurance: 48.7%
- Medicaid Only: 15.2%
- Uninsured: 8%
- Medicare + Private: 7.7%
- Medicare Only: 6.8%
Percentage of Adults Uninsured
More than 2/5 of working adults are inadequately insured
- 23% underinsured
- 11% coverage gap
- 9% uninsured
Up to 1/4 of working adults have not filled a prescription in the past year for their chronic health condition because of the cost
- highest is asthma
Characteristics of people uninsured
Young
Latina/Hispanic
Poor
Sicker
Living in South
Breakdown of Federal Budget in 2022
Social Security
- 4.8% GDP
- 1.2 trillion
Medicare
- 3.0% GDP
- 747 billion
Medicaid
- 2.4% GDP
- 592 billion
Breakdown of State Budget in 2022
- Education
- Health & Human Services
- Transportation
- Public Safety (state police officers, prisons)
- Government
Why do people need health insurance?
Healthcare is expensive and uncertain
Health Insurance in 1900s
- before insurance, patients were expected to pay healthcare costs out of pocket
- few hospitals, cash, MDs came to patient’s home
Why were costs in the past low compared to today?
there was not as much treatment options that were expensive to use and pay for
History of Health Insurance Timeline
1920s: hospitals offered pre-paid plan
1929: first employer-sponsored plan by teachers in Dallas
1935: Social Security Act — no health coverage
WWII: EMPLOYER SPONSORED PLANS OFFERED AS BENEFIT EXPANDED AS A RESULT OF WAGE CONTROLS
1946: Hill Burton Act — hospital construction
1954: tax deduction for employers in Revenue Act
Goals of ACA
- improve accessibility to coverage
- improve efficiency of care
- decrease number of uninsured
- decrease cost of care
- IMPROVE QUALITY OF CARE
30 Day Readmission Penalties
- data shows that 75% of readmissions are preventable saving up to 12 billion/year
- ACA penalizes hospitals for readmission rates
Lyndon B Johnson
- made passage of Medicare his top priority
- president truman and wife were first two medicare cards
- Medicare/Medicaid was enacted as Title 18/19 of Social Security Act in 1965
Medicare
started: July 1, 1966
health insurance for:
- elderly (> 65 yo)
- disabled
- ESKD or ALS
NO DENTAL OR EYE
NO DRUG BENEFIT FOR OUTPATIENTS
Medicare Enrollment & Spending in Future
aging population will contribute to higher Medicare enrollment
- 1966: 19 million
- 2020: 63 million
- 2060: 93 million
2021: 689 billion
2031: 1.6 trillion
Fasting growing part of Medicare
Physician service and Part B services account for the largest share of Medicare Benefit spending
Parts of Medicare
Part A
- covers hospital costs
- no premium costs
- SNF care: max 100 days
Part B
- covers physician costs & medical supplies & drugs administered in MD office — not required
- premium costs deduced from SS
Part C
- A, B, D
- managed care
Part D
- covers drug benefit
- premium costs deducted from SS
Enrolling in Medicare
- enrollment can begin about 3 months before 65th birthday (do not have to be required)
- YOU DO NOT HAVE TO ENROLL AS LONG AS YOU HAVE COMPARABLE INSURANCE PLAN
- begins when you start receiving Social Security benefits
Part A is normally free —> you do not have to accept Part B unless you do not have adequate insurance leading to a penalty
What is not covered by Part B
LTC
Dental
Cosmetic
Eye exam
Routine Foot care
Hearing Aids
Acupuncture
Medigap
- not administered by CMS but standardized by federal law
- picks up deductibles for Part A and deductibles and costs for Part B
PURCHASED THROUGH PRIVATE COMPANIES
Advantage Plan Features
- administered by private companies
- premiums CAN BE lower than regular Medicare
- offer extra benefits like vision and dental
Medicare Star Rating System
used by CMS to measure how well Medicare Advantage and Part D plans perform
- reviewed annually
- 1 to 5
Medicare Part D
- largest change in insurance processing in retail history
- not a single entity —> beneficiaries need to voluntarily enroll (average cost is 41$)
- RUN BY PRIVATE INSURANCE COMPANIES
- formularies for each plan are different
Medicare Donut Hole
- Start paying as your deductible resets in January 1
- you only pay copay’s for covered drugs
- coverage gap: you pay a certain percentage based on drug type
- your plan starts paying 100% until the end of year
Medicaid
- Started: January 1, 1966
health insurance for the poor and medically indigent
NOT REQUIRED (AZ added in 1982)
Federal-State Partnership Program in Medicaid
managed by state govt
standards by federal govt
matching funds based on state per capita income
Impact of Medicaid on US Social Welfare Program
Medicaid pays for:
- 1 in 6 dollars in HC system
- 1 in 2 dollars on long term services/supports
ACA and Medicaid
- ACA expands Medicaid eligibility for states to opt in
- allows people with income up to 138% of federal poverty level to qualify (17775 single or 36570 for 4)
- Medicaid and HC has become a political football
What percent of nation’s uninsured live in states that have opted out of Medicaid expansion?
> 50%
How does Medicaid compare to Private Insurance?
Medicaid is comparable to private insurance for access to care for adults and children
uninsured fare far less
Who spends the most per enrollee in Medicaid
Individuals with disabilities and elderly
Medicaid Drug Spending and Rebates
more money is coming back as rebates than net spending
What populations make up the most enrollment in Medicaid
- Children
- Pregnant women
What service does IN Medicaid spend the most on?
Managed Care
What percent of IN Medicaid enrollees are people of color?
39%
What percent of IN Medicaid enrollees are working?
65%
What region of the US has the majority of the states not expanded Medicaid?
Southern
70% of Uninsured Adults would become eligibile for Medicaid if what 4 states expanded?
Texas
Florida
Georgia
North Carolina
Who qualifies for Medicaid?
- low income families < 138% of FPL
- infants born to Medicaid eligible pregnant woman
- children < 6 yo & pregnant women < 158% of FPL
- certain Medicare beneficiaries
How long are pregnant mothers covered for after pregnancy ends?
12 months
Work Status of Women on Medicaid
most women covered by Medicaid work outside the home for pay
Medicaid Options
Hoosier Healthwise (MCO) –> 786,977
- children and pregnant women
Health Indiana Plan (HIP) –> 778,383
- low income adults < 138% of FPL
Traditional Medicaid (Fee for Service) –> 351,447
- > 65 eligible for Medicare
- LTC
- waiver services
Hoosier Care Connect (MCO) –> 95.582
- > 65 not eligibile for Medicare
- blind/disabled
Mandatory Services by Medicaid
LTC
Hospital
Physician
Home Health
Prenatal care
Family Planning
National Enrollment of Medicaid
60% of nursing home residents
40% of childbirths
National Eligibility of Medicaid
1/3 of all children are insured by Medicaid
60% of low income children insured by Medicaid
Dental Coverage of Medicaid
children are eligible for dental coverage; however, DENTIST DO NOT PARTICIPATE
Medicaid Reimbursement
historically reimbursed much less
- 68% normally
- 100% in 1/24
American Rescue Plan
- require federal government to negotiate prices for drugs covered by Medicare Part B/D
- require drug companies to pay rebates to Medicare
- cap out-of-pocket spending for Medicare Part D