Healthcare Finance Flashcards
eligible for MediCARE
over 65,
under 65 w/disabilities,
ESRD (any age),
ASL/Lou Gehrig Disease
basic title of MediCARE
Part A
Part A = Hospital Insurance
what does MediCARE Part A cover
hospital inpatient,
hospice,
home health,
inpt in religious nonmedical healthcare institution,
inpt in SNF (not custodial or long term care)
payment of MediCARE Part A premiums
“premium free Part A” - if you or spouse paid Medicare taxes while working
or you can purchase Part A if not eligble
basic title of MediCARE part B
Medical Insurance
- medically necessary services
- home health
- outpt
- DME (durable medical equipment) like wheelchairs, walkers, and hospital beds)
- prev med, vaccines, wellness…
payment for MediCARE Part B
most pay a standard Part B premium
policy that will cover medical services and supplies MediCARE won’t
Medigap = MediCARE Supplemental Insurance
Medigap
Medicare Supplemental Insurance
- policies sold by private companies to pay for medical services/supplies Medicare doesn’t
(copayments, coinsurance, deductibles)
name for MediCARE Part C
Medicare Advantage Plan
what is Medicare Part C
= Medicare Advantage Plan
- Medicare approved plan from a private company that is an alternative to original Medicare for health and prescription
bundled plan for Part A, B, & D
- may have lower out of pocked costs for Part A and B
- may offer certain benefits that original Medicare doesn’t offer (vision, dental, hearing)
bundled Medicare plans
Part C = Medicare Advantage Plan
what benefits may Medicare Part C offer?
- may offer additional benefits A and B doesn’t (vision, hearing, dental…)
- may have lower out of pocket costs
Medicare Part D
Prescription Drug Coverage
- may be run by a private company that follows Medicare rules
- may help lower Rx costs and protect from higher future costs
eligible for MedicAID
primary health & long-term program for 83M lower income
% of costs assumed by MedicAID
1/5 of healthcare spending,
1/2 of spending for long-term care,
&
large share of most state budgets
who pays for MedicAID
joint financed by the state & federal government
BUT
administered by the state w/broad rules
why is Medicaid run so differently?
states get flexibility in which populations/services to cover, how to deliver care,
and how much to reimburse providers
Medicaid in 2025
many issues at play affect Medicaid coverage, financing, and access to care
- Trump may use executive action to make changes to Medicaid
- Congress may make changes as part of tax and spending debates
Nationwide & state breakdowns of populations on Medicaid
Nationwide = 21% of Pop
11% Utah
34% New Mexico
6 states are under 15% (NH, Utah, Kansas, Dakotas)
18 states = 15-20%
19 states = 20-25%
8 states = greater than 25% (NM, Louisiana, Kenducky, W. VA, NY, )
characteristics of states that have high % of population on Medicaid
- % higher in the 41 states that chose to expand Medicare under the Affordable Care Act (21 Trump voting states/20 Harris voting states)
- rates are higher in states w/lower average of income & lower rates of health insurance offered through employer)
MedicAID as a key source of coverage
1 in 5 Americans have it,
4/10 of kids,
8/10 kids in poverty,
1/6 adults, 1/2 of adults in poverty,
41% of all US births
1/2 of special needs kids,
5/8 nursing home residents,
29% nonelderly adults with mental illness,
40% nonelderly w/HIV
wraparound coverage
policy that provides broad comprehensive liability co er encompassing owner, contractors/subcontractors. often used to avoid gaps or insufficient limits in individual policies
- often used in construction
relationship between Medicare and Medicaid
MedicAID pays Medicare premiums to offer wraparound coverage for services not coered by Medicare
(example: for most long-term care) for 1/5 of Medicare beneficiaries (13M)
key source of coverage for homeless and those transitioning out of carceral settings
Medicaid
funds Medicaid
Medicaid is joint funded by state and federal gov
- states are guarenteed federal matching $ w/o a cap for qualified services provided to eligible enrollees
- match rate for most is a formula that match and es at least 50% provides a higher match rate for states w/lower per capita income or a higher rate for certain services and populations
FY 2023 Medicaid spendiong
$880 Billion (69% of which was federal spendiong)
when does Medicaid spending increase
Medicaid spending increases during economic downturns b/c people may lose income and enroll in the program
FFY
federal fiscal year old
FMAP
Federal Medicaid Assistance PErcentage
SDOH
social determinents of health
benefits of Medicaid not in Medicare
provides benefits not usually offered by health insurance
- nonemergency transport to appointments, EPSDT
(early periodic screening diagnosis and treatment for kids)
EPSDT
Early and Periodic Screening, Diagnostic, and Treatment
- federal law that provides comprehensive and preventative health services for children under 21 who are enrolled in Medicaid
% of total payments for services that are sourced from Medicaid
61% payments for long-term care are from Medicaid (39% others)
19% hospital
18% providers
11% drugs
11% dental
seniors & those with disabilities
- % enrolled compared to the spending on them
seniors & those w/disabilities are 23% of Medicaid enrollment
BUT
use 51% of the spending
**seniors/disabilities have higher healthcare costs for more complex needs, higher chronic disease rates, more utlilization, and more likely to require long-term care
kids as the enrollment % of Medicaid and their utilization
kids are 34% of enrollment but 14% of spending
state requirements for Medicaid
all states are required to provide some Medicaid benefits but many are optional (vision, prescription rx, dental…)
- choice of how much to spend per enrollee, what benefits are covered and how much providers are paid…)
spending (in 2021) for Medicaid per enrollee
- nationwide
- by state
nationwide = $8,000 per enrollee
9 states = under $6K
13 states = $6-7500
19 states = $7-9K
over $9K = 10 states including NH
DC spends the highest of all states…$12K per enrollee
how do 75% of Medicaid enrollees receive their care
75% of Medicaid enrollee receive care through comprehensive risk-based managed care organizations
- 5 for-profit parent firms account for 50% of all Medicaid MCO enrollment (Centene, Elevance, Molina, United Health Group, CVS)
- they are paid a set per member per month payment for services
- states have increased reliance on MCO w/aim of improving access to certain serviecs, enhancing care coordination management, and making future costs more predictable
what does Medicaid cover facilitate
Medicaid coverage facilitates access to care, improves health outcomes, and provides financial protection from medical debt
what does research show about Medicaid benefits
Medicaid beneficiaries get better access to care than uninsured
less likely to postpoine or go w/o care due to costs
(federal rules generally limit out of pocket costs for Medicaid)
problem w/Medicaid
- gaps to access of certain specialties (dentists & psychiatrists)
- provider gaps in low income communities, Medicaid lower physician payment rates, lower Medicaid physician participant compared w/private insurance
physician reimbursement per types of insurance
Medicaid reimburses substantially below other provider rates
benefits of Medicaid on children
positive health effects like avoidable hospitalization, long-term educational attribution, increased economic security, decreased morbidity & mortality, and early cancer detection
NBER
National Bureau of Economic Research
access to care as reported by Medicaid & private insurance enrollees
both report similiar access to care. and both have better access to care than the uninsured
how do Americans report they view Medicaid
77% of Americans view it favorably,
63% Republicans,
81% Independents,
87% Democrats
- 62% of those who voted for Trump view it favorably
opinions of Americans on Medicaid spending
46% say the federal gov doesn’t spend enough,
19% says the gov spends too much
what to remember when looking at stats of what type of health insurance Americans have & the number doesn’t neatly add up to 100%
some Americans have more than one type of health insurance
how do most people get their private insurance
most people get health insurance privately through their employer
6 types of public health insurance
Medicare,
Medicaid,
CHIP,
TRICARE,
federal health plans,
state health plans
CHIP
Children’s Health Insurance Program
demographics that influence the type of insurance a person has
age
income
disability
state
what demographic has the highest heath insurance coverage rate
kids under 19 (94% covered) b/c Medicaid & CHIP cover low/moderate income
- 19-26 yro olds who were working in 2014 were 86% covered
private health insurance
agreement that a state licensed health insurance/benefits plan will take on the financial risk for healthcare costs, administer benefits, and pay claims for clients
sells insurance to employers
group maket
sells health insurance to individuals (not their employers)
individual market
health insurance sold for profit
commercial health insurance
BCBS
Blue Cross/Blue SHield
- nonprofit (in parts of CA, NJ… but for profit in NH)
- has a more community forcus that commerical income
- states regulate these plans and may have stricter requirements for preexisting conditions and experience ratings to make it more affordable to the state)
HMO
Health Maintenance Organizations
- integrated health insurance w/provisions fo rmedical care
e.g. Kaiser Permanente
Kaiser Health Plan
type of HMO (Health Maintenance Organization)
- Kaiser Health Plan has exclusive relationshipo with Permanente Medical group. owns hospitals, imaging centers, clinics…doesn’t cover outside care
not truly HMO plans
most commercial health insurance products offer some HMO but not truly HMO b/c the insurer does not own facilities or contract exclusively w/providers
individuals & employers pay insurers for health insurance
versus
self-insured
thus, the insurer takes on the risk of illness or injury
…
when you don’t haveinsurance, you take on the risk yourself. you are responsible for the premium that will cover the medical costs for their employer.
why are large employers able to self-insure
large employers have the capacity to assume risk b/c it is spreading out the risk & spending over many individuals
ERISA
Employee Retirement Income Security Act of 1974
why do employers that have the capacity to take on risk choose to do it?
- saves $
(manage own benefits and pay claims in house. purchase 3rd party to cover anything that can’t be managed in house - under ERISA< self-insured plans are exempt from many state regulations for fully insured plans
(“deemer clause”, ERISA section 514 states may not deem self-funded plans in order to subject them to state regulations - protects multi-state employers from facing inconsistent obligations in different states so they can give iemployees in different states the same package of health benefits_
purpose of the deemer clause
under ERISA, self-insurance plans are exempt from many state regulations for fully inured plans
the deemer clause protects multi-state employers from state regulations. so they can give employees in different states (under different state regulations) the same health benefits package
most common type of private health insurance
employment based coverage is the most common type of private halth inurance coverage
who works but doesn’t have employment based health coverage
part-time,
Seasonal,
unemployed,
firms with fewer than 10 employees often doesn’t,
spouses/dependents of those w/o coverage
these people not on an employee sponsored plan are often smaller firms. they can still purchase on the individual market
COBRA
federal program for non-fed workplace w/ greater than 20 employees
- may buy into fomer employers plan for 18-36 months,
employer isn’t obligated to make any contributions to the premiums so it can be costly
options when you lose your job/transition in-between jobs
transitional options
- change jobs, move, take on too few hrs for coverage eligibility, divorce/separation from spouse who has coverage,
kids age out,
spouse dies/ages out and is now Medicare eligible
- workers or their spouses who depended on them become eligible under COBRA
benefits/costs of employer based health insurance
- employer/employee premiums for health insurance are exempt from fed/state insurance takes, social security, and medicare payroll tax
- thus, may have more generous benefits than individual market policies b/c tax exempt
- also beneficial b/c it ties the employee to the employer
public health insurance
government agrees to take on fanancial risk for healthcare costs, administer benefits, pay claims, or contract w/3rd paty benefits for employees and families
6 government healthcare programs
Medicaid
Medicare
SCHIP
VHA
Indian Health Services
Medicare/Title 18 of the Social Security Act
federally administered program of health insurance for the eldery and disabled
A - Hospital Care
B- Physician, Imaging, Lab
C- set of managed care optiosn that are privately offered alternatives to traditionally offered A, B, D
D- Outpatient prescription rx
not covered in traditional Medicare
long-term care,
assisted living,
vision,
Dental,
hearing exams/aids
Medigap
optional supplemental insurance to pay for out of pocket costs not covered under Medicare/Part C
- private-not publically- offered
- out of pocket costs like deductibles, copyayments, coinsurance
- Medicare doesn’t subsidize premiums for Medigap purchases but some employers do offer Medigap policies
payment for Medigap
Medicare does’t subsidize premiums for Medigap purchases
- private not publically offered
- some employers do offer Medigap policies
Qualified for Medicare
over 65yrs if US citizen and at least 5 years of continued residence,
adults under 65 who are receiving SSDI payments for 24 months,
ESRD/ALS dx covered as soon asy you start receiving SSDI payments
SSDI
Social Security DIsability Income
what eligibility must you meed in order to be eligible for Medicare for the non-age related reasons?
SSDI payments = Social Security Disability Income
under 65 w/a qualifying disability = eligible for Medicare once you have been receiving SSDI payments for 24 months
ESRD/ALS diagnosis = eligible as soon as you receive your first SSDI payment
when are you eligible for Medicare Part D
eligible if you are enrolled in Part or B
when are you eligible for Medicare Part C
if entitled to Part A
and
enrolled in Part B
enrollment in Medicare Part A
enrollment in Medicare Part A is automatic for anyone who qualifies for Social Security based on age or disability
HOWEVER
you may pay the premium to enroll if not eligble
what finances Medicare Part A
Part A is financed through a 2.9% payroll tax
(1.49% from employers and 1.49% from employees)
IF higher earnings, the payroll tax is 3.8% (2.3% each)
AND
payroll taxes fund the Hospital Insurance Trust Fund which pays Part A benefits
what do payroll taxes fund-
payroll taxes finance Medicare Part A = fund the Hospital Insurance Trust FUnd
Hospital Insurance Trust Fund
“HI Trust Fund”
- aka Medicare Part A
- finances healthcare services related to hospital stays, skilled nursing facilities, and hospices for eligible beneficiaries
- primarily funded by payroll taxes and income from the taxation of Social Security Benefits
financing for Medicare Part B
Part B = SMI Program
(Supplemental Medical Insurance)
- pay a premium to enroll but these premiums are heavily subsidized by general tax revenue
- premiums finance 1/4 of Pat B and the remainder is funded primarily by general tax revenue
what must you do immediately enrolling in Medicare Part A
financial penalty for failing to immediately enrolling in Part B post eligibility (10% per yr) to reduce adverse selection
Medicare Part C
“Medicare Advantage”
- 30% of Medicare are enrolled
- offers benefits not traditionally covered by Part A & B
finances Medicare Part C
financed in part by subdisized premiums
AND
by the HI Trust Fund for inpatient care
who is eligible for Medicare Part D
if enrolled in Part A and B
- can purchase a private stand-alone prescription Rx Plan (PDP)
- if in part C, you may enroll in MA-PD (Medicare Advantage Prescription Drug Plan)
finances Medicare Part D
Part D is private so financed by premiums
- 3/4 of the costs are from general revenue and the rest is premium or state funded
Could Medicare go bankrupt?
would apply to Part A (Hospital Insurance Trust Fund)
- HI Trust Fund is funded almost entirely by payroll taxes
- so as population ages, too many beneficiaries and too few contributors to payroll taxes
- thus, Medicare will have to cover hospital benefits from other $ sources to keep going (not the HI Trust Fund financed by the payroll tax too few would be paying into)
- to ensure steady funding for Part A benefits, Congress needs to enact policy changes to strengthen the Trust Fund (like higher payroll taxes)
- Medicare wouldn’t actively cease hospital insurance to exist or become bankrupt. they’d just need a different funding source
why are Medicare Parts B, C, & D considered at risk for failing/running out of $ like Part A?
Part A’s Hospital Insurance Trust Fund is funded by payroll tax. the concern is too few would be paying in while too many would take money out.
- Part BCD are funded mostly by premiums and general revenue so not at risk
- to understand the impact of the concern, you’d need to focus on Part A benefits and fundign sources
income of most Medicare beneficiaries
most Medicare beneficiaries have modest incomes
- 4 in 10 have annual incomes below $20K
- 59% have incomes over $20K rely on employer health benefits or Medigap to fill in benefits gaps
act that covers Medicaid
Medicaid = TItle 14 of the Social Security Act of 1965
act that covers SCHIP
Title 21 of the Social Security Act of 1965 = State CHildren’s Insurance Program
largest health insurance program in the US
Medicaid & SCHIP
who administers Medicaid & SCHIP
states
BUT
benefits/eligibility must meet (or exceed) federal baselines in order to bve eligble for federal funding
federal funding = 50-83% if program costs depending on state per capita income
thresholds for federal funding for Medicaid/SCHIP
must cover children over 6yo,
up to 100% of the federal poverty line,
pregnant and under 6yr earning up to 133% of the federal poverty line,
elderly and disabled who receive SSI benefits up to 75% of the federal poverty line,
very low income parents eligible for welfare benefts
- states may get federal funding to cover above threshholds.
- AC states that have expanded Medicare to non-elderly up to 138% of the FPL and federal government will cover nearly all costs of the additional recipients.
- in states that didn’t expand, income and asset requirements vary considerably
why is Medicare considered an entitlement program
b/c anyone who meets eligibility requirements may enroll
qualified for Medicaid
if meet federal/state requirements of residency, immigration, and citizenship
basic requirements to receive federal funds for Medicaid
states have some flexibility for designating Medicaid benefits BUT basic requirements for federal aid…
- hospital inpt/xray,
SNF for over 21yo
- health clinic sercie
- pregnancy with 60 days postpartum
- kid vaccine
- family planning and supplies
- home health for eligible persons
pregnancy requirements for states to receive federal funds for Medicaid
pregnancy & 60 days postpartum
what does Medicaid cover that Medicare does not
the fact that medicaid covers nursing facility care and home health is noteworthy b/c mediCARE only gives limited coverage and private insurace doesn’t often make this affordable
SO
Medicaid is the primary payer fo institutional and community long-term care
primary payer for institutional and community long-term care
Medicaid is the primary payer
how do states that don’t comply w/fed minimum for benefits and eligibility still receive matching funds for Medicaid
w/a waiver
- waiver profisions like charging premiums, eliminate certain benefits to expand coverage, and mandatory enrollment in managed care
Tricare NEVER covers
NEVER: nursing home,
long-term care,
custodial care,
assisted living
NORMALLY DOESN’T cover: services supplies not medically necessary, pregnant and well-child care
% of Tricare that is active duty
20% = active duty
26% family
VHA =
Veterans Health Administration
- a provider, not insurance plan
- comprehensive medical, in/out pt, prev med, health promotion, mental health
VHA and billing for conditions not r/t medical service
VHA bills the vet’s private insurance but doesn’t bill MEdicaid/Medicare
- copay if nonservice related condition (the low income are exempt)
but
serice related conditions are covered at no additional cost to the vety or insurer
eligible for VHA
if separated from the military for anything other than dishonorable
BUT
dependents aren’t eligible
what is Indian Health Service
provider not insurer
financing for the Indian Health Service
- users don’t pay premiums, deductibles, and copayments
- IHS doesn’t bill insurers for care- they contract provifders directly and pay direct to IHS facilities
- limited funding so mostly just inpt/outpt, ambulatory, dental, adnpedis
yr of the Great Recession
2007 - 2009
uninsured between 1965 (Medicaid/care) & the Affordable Care Act (2014)
steady 15% was uninsured
- after ACA, 9% was uninsured
public insurance
usually single benefits package at a fixed price
private insurance
wide variety of plans at different prices and benefits level
- compete for contracts so innovation tools and products
- lets employers tailor to needs and preferences
(e.g. elderly don’t want children/family planning. younger do. elderly are more interested in services for hospital and chronic condition care
private health insurance is often linked to
most private insurance is tied to employment so lose coverage when you change jobs
- makes people vulnerable to losing insurance when they are vulnerable and need it most
- job based coverage leave out self-employed and unemployed
job lock
employer based coverage interferes with job mobility which leads employees to take inappropriately matched jobs to skills/interests post to maintain health insurance coverage
taxing employer based health insurance
employer based health insurance premiums aren’t taxed
- this favors higher earners and results in loss of billions of dollars in revenue
b/c so many americans have tax free employer based inurance estimate total revenue loss to federal gove is $248B
problem of tax insurance
- employer based premiums are tax free so the government loses billions of dollars of revenue
- tax advantage causes overinsurance (could spend money but it would be taxed. could put into retirement but can’t spend for decades…or could contribute tax free money to pay for premiums on an upgraded health plan
…so employer based health insurance encourages peopel to be more generous with plans and benefits than if their plans were purchesed by tax
what is actually happening when employers contribute to health insurance premiums
employers usually contribute to the premium but employers may pay for the program w/.ower wages and slower growing wages
..sick/disabled/childbearing cost more to insure but employers can’t legally lower their usage b/c distribution so hire less often
what does public insurance fill
public insurance fills gaps in the market and covers most vulnerable populations
- strengthes of gov insurance ist he size which means the gov has enormous influence over providers (providers must accept prices or lose a large volume of business)
benefit of public insurance
strength of government insurance is the size of the enrolleees. providers must accept prices or lose a large volume of business
why isn’t public/gov insurance always enough
individuals vary in needs and preferneces so sometimes public/gov insurance is too little/much
finances Medicare Part A
Part A is financed through payroll taxes so insolvency of the HI Trust Fund at risk of too few paying payroll taxes
Q’s to ask about hte uninsured
Who are they?
Why?
What are the consequences?
What programs are for them?
status of health insurance in 2014
bc of the ACA, almost all Americans had to have health insurance
yet
people were still uninsured
How many people are uninsured?
answer depends on how you frame the question
…
were you uninsured for the entire yr?
are you uninsured now?
uninsured at any time last year?
framing of the question asks about chronic uninsurance (lower estimate) versus periodic unemployment (higher estimate and includes people who are insured now)
survey questions are subject to
recall periods (low for participants that have to remember farther periods of time back)
how the question is framed
elderly who are uninsured
less than 1% of the uninsured are elderly b/c Medicare so most uninsured are under 65
% of people 18-64 of the population & % of the uninsured
24% of the population but is 38% of the uninsured
“young invincibles? b/c before healthy enough to not need insurance and have low rates of chronic diseases
why is it odd that men are less likely to be inured
odd b/c men are more likely to work so they are more likely to be covered by employer inurance. but also not odd bc some states don’t give Medicaid to healthy young men
immigrants and Medicaid
some states make immigrants wait to be eligible for Medicaid
uninsured who work
70% of the uninsured actually do work
- 54% have full time jobs
why does geography impact the uninsured
geogrpahy impacts the uninsured b/c states vary in public healthcare eligbility and poor congregate in teh south
- south = 37% of population but has 47% of the uninsured
- highest uninsurance rates = TExas -19%, AL 17%, FL 17%, GA 16%, MA 3%, DC 5%, HI 5%
HI implemented health insurance expanses before the ACA
MA did employer/individual mandates, and MEdicaid expansion in 2006
reasons people don’t have health insurance
60% bc of cost,
20% don’t want it,
14% bc/ transitioning between coverage,
10% no time or didn’t know how to get it
ACA requirement in 2014
required all ot get health insurance and provided subsidies - yet people were still uninsured
- ***subsidies were only avilable to 100-400% of the federal poverty line so earn less and get Medicaid
- Supreme COurt said states were not required to expand (NFIB v Sieelius 2012)
- most already did so those small firms were les slikely to be covered
ACA required employers with __ employees to…
with more than 50 employees to provide health insurance or pay a penalty to finance coverage
- most already did so those small firms were less likely to be covered
why didn’t the ACA individual mandate work
people could pay a penalty to avoid the individual mandate
annual penalty = 2.55 of household income or ($695/adult & $347/kid)
whereas the average cost of the annual premium =
- $1800 indivudual or $4400 employer group rate
….so in 2015, 1/5 of uninured paid the penalty
who is exempt from the individual mandate
those most at risk for being uninsured are exempt from the individual mandate
- live in states that didn’t expand medicaid but would have qualified if they did
- eligible for the Indian Health Service
- hardship exemptions (DV, homeless, evicted, bankrupt)
- earn too little to file tax return
affect of not having health insurance
no health and financial security
- not protected from catastrophic medical costs so profound consequences for how they interact with the healthcare system
problem of not having health insurance
insurance protects against catastrphic out of pocket costs but uninsured have no one with whom to share risk
- if decide/forced to engage w/the medical system, they’d lack benefit of negotiating power for prices of servies
…w/o an insurer to pay, they pay the list price (menu). even though they are poorer, they will pay higher
uninsured can negotiate but insurers typically get farther b/c they negotiate on behalf of thousands of enrollees
who has the most medical debt
the insured (versus uninsured)actually have more medical debt and difficulty paying b/c they interact wless with the healthcare system
- casual link between uninsurance and financial distress goes both ways
what factors contribute to health
health is a combination of social and enviornmental factors as you can’t attribute entirely of health to the heatlhcare system
good and bad impact of medicaid
medicaid might lead to higher employment and earnings bcbetter health = better performance and less lost work days
BUT
Medicaid may decrease earnings bc/ peopel stay in poor paying jobs to keep medicaid eligibility
THUS
the insured NOT uninsured assume more medical debt
benefit of coverage expansions
coverage expansions ease financial strain
problem of poor health
difficult to hold steady jobs that ensure high insurance
1974 Hawaii Prepaid Health Care Act
required employers to offer health insurance to alll workers over 20hr/wk
0 mandate did increase some coverage but others shifted to part time work to be exempt
MA expanded health coverage
2006
- Mass has some of the lowest uninsurance rates (43%)
- individual mandate (must have health insurance)
- employer “pay or play” (offer health insurance or pay a penalty)
- expanded medicaid
- opened online marketplace to offer standardized subsidized plans
- differens in state policies make MA lower in rates - like the individual mandate
everyone has to have health insurance
individual mandate
2006 health insurance plan
“Healthy San Franscico”
- like insurance but not generous enough to be health insurance
- for lower/middle income San Fran who didn’t wqualify for publci assistance but had been uninsured for 3months
- for a small fee, they coudl go to public hospitals/clinics
- for a time, line item at the bottom of restaurant bills was
Healthy SF Surcharge” which was how restaurants health insurance to staff
compensation paid by one member of an unmarried couple to the other after separation
palimony
advice for the uninsured
check healthcare.gov to see if you qualify for Medicaid or subsidized private health insurance than health insurance marketplace
- insurance is critical component of good health
- not necessary going w/o care or paying lowest price
if uninsured & need care, you can negotiate before you go in
find out what a bundle of services cost at guroo.com or healthcarebluebook.com to see area costs
EMTALA
must stabilize/transfer if medical emerpgency
- EMTALA doesn’t restrict providers from billing uninsured pt from their services - just from turning you away
- may negotiate bills and most hospitals check to see if you qualify for MEdicare/Medicaid
findaahlesthcenter, hrsa.gov
community health may be lower than traditioanl and waive fees ore do a sliding scale for those who can’t afford them
- community health general focus is low income. urent care would be higher
primary reason people are uninsured
cost
monthly payments for insurance
premiums
premiums
monthly payments for enrollees in insurance
- like a group piggybank where employees and employers pay in
who pays premiums for Medicare/Medicaid
state/federal gov
difference between copayments and coinsurnace
copay - amount
coinsurance - you pay a percentage of hte bill
you pay an amount per usage
copay
you pay a percentage of the bill
coinsurance
out of pocket payments before insurance kicks in
deductible
maxumum you’ll pay per year after that, insurance will pay 100% of everything else
out of pocket max
medications your insurance will pay for
formulary
doctors who are part of your plan. insurance negotiated discounts and use their docs, you’ll get those discounted rates
provider network
why might you sometimes go out of network with providers
your surgeonj may be in network but your ANES out of network- you can file an appeal with insurance or negotiate
tradeoffs with insurance
sometimes a larger network of provider but you’ll have larger copays and deductibles
