Intro to Medicare and Medicaid (10/1b) [Integrative Care] Flashcards
Social Insurance Model vs Public Assistance Model
Social Insurance Model - requires a contribution to receive a benefit
Public Assistance Model - those who contribute (taxpayers) may not be eligible for benefits
Medicare - Overview
Social insurance model
Enacted in 1965 as just parts A and B, less people used to have insurance before because employed based and high risks
Tax financed, married government insurance and privately operated health services
4 parts (A-D)
4 Parts of Medicare
Part A – Hospital Insurance/inpatient (original)
Part B – Physician Services/outpatient (original)
Part C – Medicare Advantage Plans (1980’s) (involvement with HMOs and PPOs)
Part D – Medicare Prescription Drug Plan (2005)
Medicare Part A
Coverage for hospital inpatient, skilled nursing facility, home health and hospice
ELIGIBILITY - for 65yo eligible for social security and spouse auto enrolled (regardless of retirement), less than 65yo but permanently disabled, chronic renal disease, ineligible people who pay monthly premium
FINANCES - through social security, payroll tax, self employed tax
COVERAGE TIME- first 60 days covers all necessary costs besides $1340 deductible, increases OOP cost 60-150 days, beyond 90 days only pays 60 additional days once in lifetime
Medicare Part B
Coverage for physician services and outpatient
ELIGIBILITY - people who are eligible for Part A but choose to pay Part B premium
FINANCES - financed 75% by fed tax and 25% by monthly premiums, higher premium if higher AGI, $184 deductible/yr
COVERAGE - covers 80% of approved amount (after deductible) for medically necessary medical expenses like physician/PT/OT/ST/diagnostic tests, no OOP for preventative care like vaccinations/mammo/pap smear, doesn’t cover outpatient meds/eye refractions/hearing eval/dental
Coverage for Therapy Services
Financial limitation (Cap) for outpatient rehabilitation services in 2019
PT & Speech Therapy (ST) share one $2040 “cap” for both therapies combined as of 2019
$3,000 “threshold” – record review
OT services have a separate $2040 “cap”
Medicare Therapy “Cap Exceptions” extended permanently as of 2018 and doesn’t require Congressional approval every year (requires KX modifier)
Medicare Access and CHIP Reauthorization Act (MACRA) 2015
SGR – repealed & avoided deep cuts to PT
Therapy Cap – repeal not approved by 2 votes
Payment Reform – Value-based payment
(They will not reimburse provider for each item of care they bill for (fee for service model) because it incentivizes providers to add on many services)
Created Merit-based Incentive Payment system (MIPS) [private practice PT participate 2019]
Incentives for participation in Alternate Payment Systems (APM)
Medigap
Supplemental private insurance – purchased by former employers or beneficiaries themselves to pay for deductibles and coinsurance or gaps in coverage, frequently used with Parts A and B
10 standardized plans – rated pricing.
Estimate > half of the 50 million Medicare beneficiaries carry supplemental ins
20% had dual enrollment in Medicare & Medicaid
1/3 Medicaid budget used to cover Medicare coverage gaps in Nursing home & Rx drugs
Medicare Part C
Medicare Advantage Plans
Medicare contracts with private insurance companies to enroll Medicare eligible persons and provide coverage for hospital, physician services (Part A& B) and some Rx drugs
Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs)
PLANS - Plans can require referrals with high copays for specialists, can cover drugs/dental/vision
FINANCES - lower premiums, 15% cost sharing arrangement
Medicare Part D
Prescription drug coverage
Increase role of private health plans to provide covered benefits (formulary, generic brands, co-pay & coinsurance)
FINANCES - $360/yr deductible, $13/mo + premium
ACA gradual closing of donut hole
Medicaid - Overview
Public assistance model
Federal program (50% to 85% cost covered), but administered by the states
Feds require certain categories of low income people be enrolled in State Medicaid programs
Expanded significantly with ACA 2013
Medicaid - Eligibility
Low income families with kids
Elderly, disabled, blind under federal supplemental social security
Children under 6
Adults with fam income below 150% fed poverty ($35k fam of 4)
Kids under 19yo with fam income at/below fed poverty level ($25k fam of 4)
Medicaid - Requirements
Federal Government requires states to provide a broad set of services under MA
Hospital, physician, laboratory-ray, prenatal, preventive, nursing home and home health services
Medicaid Waivers – gives states more control in program beneficiaries and scope of services and required enrollment in managed care plans and healthcare exchanges under ACA (Pennsylvania)
State Children’s Health Insurance Program (SCHIP)
Covers uninsured kids in families with incomes at/below 200% poverty level but above Medicaid eligibility
States with this program receive generous fed matching funds
Created in 1997, expanded 2003-2007, PA eliminated 6 mo wait period in 2013
Affordable Care Act
(March 2010)
Mandates health insurance coverage-2013 with fines & penalties on individuals & businesses that fail to comply
Supreme Court upholds law as a tax congress is authorized to levy – June 2012
