Medicare and Medicaid Flashcards
Social Security Act Ammendments of 1965
Passed by LBJ as part of The Great Society.
Title 18 created Medicare, and Title 19 created Medicaid.
Overall mission of Medicare
To provide care for the elderly.
Overall mission of Medicaid
To provide aid for the poor
Eligibility for medicare
Eligibility is automatic at age 65 if Social Security eligible (>10 yr worked in US labor force by enrollee or spouse)
Permanent disability and chronic disease groups are also eligible after a 2 year waiting period following their application to SSDI.
End-stage renal disease patients are eligible after 4 months of dialysis
ALS patients are eligible with no waiting period following their application to SSDI.
“Traditional Medicare”
Parts A, B, and D
Part A Medicare
Covers inpatient hospital visits, skilled nursing and rehabilitation costs, and hospice/home health expenses
No premium (for most), $1,364 annual deductible, variable coinsurance depending on utilization (1-60 days are free, 61-90 days are $341/day)
Part B Medicare
Covers physician services, outpatient care, diagnostic tests, preventative and screening tests, durable medical equipment, and physician-administered drugs
$135 premium, $185 deductible, all preventative services free, 20% coinsurance for all other services (this last part may be quite expensive, as when patients are admitted under observation status, which may cost thousands)
Part D Medicare
Most recently enacted, in 2003, as part of the Medicare Modernization Act. Covers perscription drugs.
This reflects the shift in medicine towards managing chronic conditions in the past several decades.
Things medicare does not cover
Custodial long-term care (>90 days)
Hearing aids
Dental care/dentures
Cosmetic services
No out-of-pocket maximum
It should be of note that protections added in the ACA. . .
. . . did not extend to the Medicare program
Medigap plans
Additional supplemental plans that help shield patients from other out-of-pocket costs not covered by Medicare.
1/3 of Medicare participants have a Medigap plan as a retire benefit from an employer.
25% buy their own private Medigap plans
18% are dual-enrolled in Medicare and Medicaid, and Medicaid acts as their Medigap plan
23% do not have a Medigap plan.
Medicare Advantage (or MA, Medicare Part C)
Medicare packages administered by private insurers. Not available everywhere. Have network restrictions, unlike traditional Medicare. Simplified cost-sharing rules, and sometimes include dental or vision or other benefits traditional Medicare doesn’t offer.
Do have out-of-pocket limits, so there is no need for a Medigap plan.
Sometimes also requires a Part D plan to determine drug availability and cost.
Medicare Advantage plans have been . . .
. . . growing in popularity substantially in the past decade (from ~13% of Medicare beneficiaries in 2003 to ~33% in 2017)
Pathways in Medicare
Future of Medicare
The largest healthcare insurance program in the US
Medicaid
Medicare vs Medicaid
Medicaid joint-financing
For every dollar spent on Medicaid by a state, the Federal government will also supply a certain ratio of money. This matching formula varies by state and is based on average household income.
In MA, it is 50/50. In Mississippi, it is 24/76 state/federal.
Medicare is a ___ share of state budgets.
Medicare is a growing share of state budgets.
It has roughly doubled from ~10% to ~20% of state budgets in the past 30 years.
Mandatory Medicare coverage
- Inpatient and outpatient hospital care
- Physician services
- Laboratory tests and imaging
- Family planning services except abortion (no federal money may be used to pay for abortion, by law)
- Long-term nursing care (after that 90 day period for many on Medicare)
Copayment in Medicaid
Generally nonexistent or only nominal. Additionally, many groups are exempt from paying even the nominal amounts.
Optional Medicare coverage
Varies from state to state.
- Prescription drugs (technically optional, but all states cover)
- Dental care/dentures
- Optometry/eyeglasses
- Hearing aids/prosthetics
- Physical therapy
- Hospice
Medicaid Payout to Hospitals
Reimbursement rates relatively low, vary state to state. Some providers choose not to participate due to low rates.
This is why public and community hospitals are so important for serving Medicaid beneficiaries.
Managed Care in Medicaid
States have largely moved away from managing their own plans towards paying a private firm to manage their Medicaid program.
Behavior health benefits are often delegated to a secondary private plan, which may result in fragmentation of care.
Major difference between Managed Medicaid Care and Medicare Advantage
The beneficiaries do not choose whether or not to participate in Managed Medicaid Care, the way they do in Medicare Advantage. Rather, the state decides to participate in Managed Medicaid Care and all of its residents must comply, as there is no other state option outside of the private market.
2014 ACA Expansion of Medicare
Expanded Medicare to cover all citizens with incomes below 138% of the Federal Poverty Line (about $35,000 for a family of four).
Supreme Court Ruling on ACA Medicare Expansion of 2014
The Supreme Court ruled that this expansion must be voluntary, not mandatory. Thus, several states have decided not to undergo this Medicare expansion. Unfortunately, these are states that have historically high rates of uninsurance, where the effects could have been most beneficial.
Most of the coverage gains in insurance as a result of the Affordable Care Act are the result of. . .
. . . Medicaid expansion.
The Oregon Health Insurance Experiment
Randomized people into Medicaid coverage. Found that:
- Utilization of all services increased, including ER
- Increased access to care and use of preventative services
- Improvements in self-reported health and financial security
- Decreased self-reported depressive symptoms
- Increased diagnosis and treatment of depression and diabetes
- No improvements in cholesterol, A1c, or blood pressure, but these may be limited due to statistical power
__ and __ make up the majority of Medicaid enrollees, but __ and __ utilize the majority of Medicaid funds.
children and adults make up the majority of Medicaid enrollees, but elderly and disabled utilize the majority of Medicaid funds.
Prior to the passage of the ACA, coverage was available only to low-income individualsin thesecategories ofeligibility:
children, pregnant women, parents, elderly adults,and people with disabilities
Retrospective Medicaid Eligibility
Necessary to address the near 25% of eligible uninsured individuals under 65 who do not know that they are eligible for Medicaid. They can be provided care and then signed up and covered by Medicaid post-hoc.
However, the Trump administration is granting states waivers to suspend Retrospective Medicaid eligibility, creating worse health outcomes for the poor in these states.
