Medicare/ Medicaid Flashcards
What is Medicare and Medicaid and Why Are They So Important?
Medicare and Medicaid are government health insurance programs by which the federal government (Medicare) and state & federal government (Medicaid) pay for health care
Medicare covers certain services and their coverage decisions are important, not only because it directly affects those who use Medicare (called “beneficiaries”), but insurance companies often follow Medicare coverage guidelines
medicare (federal)
- mainly for the elderly ( over 65)
- Memory device: You “care” about your grandparents, so Medicare is the federal program caring for the elderly by providing them health care coverage
- ELDERLY PEOPLE ARE NOT THE ONLY GROUP COVERED BY MEDICARE– it also covers other groups, but this is the big one
medicaid (state & federal)
- mainly for low income individuals
-Memory device: When you donate clothing or food, you are providing “aid,” so you are aiding those in need
what are individuals who qualify for both medicare and medicaid coverage referred to as ?
dual eligibles
-responsible for a high amount of health care costs to the system as they tend to have numerous complex health care issues, so accordingly, potential health care cost reduction solutions tend to focus on this population
The federal government enacted Medicare in 1965 as part of the Social Security Act to reduce health care costs for:
Individuals older than 65
People with permanent disabilities
People who have been exposed to environmental health hazards
Individuals of all ages with End Stage Renal Disease
Medicare is federal heath insurance; it is considered an entitlement.. what does entitlement mean?
“Entitlement” definition: individuals who qualify have a legal right to (are entitled to) and are guaranteed benefits from a government program as granted through legislation authorizing the program
what are examples of entitlement?
Medicare, Social Security, and Medicaid
What are the four main components of medicare according to the law?
- Part A: Hospital Insurance (inpatient)
- Part B: Medical insurance (outpatient)
- Part C: Managed care (medicare advantage plans - HMO or PPO)
- Part D: Prescription Drug Benefit ( outpatient prescription drug Insurance)
(T/F) Beneficiaries pay a monthly premium to obtain Part B or C and for Part D; they do not have to pay to obtain Part A because Medicare taxes are already taken out of their paycheck during their working years, but they may have a deductible for hospital costs (about $1000)
true
There is also Medicare Supplement Insurance called
Medigap
HMO and PPOs are types of managed care plans that…
contract with health care providers and facilities to provide health care at a reduced cost within a network
PBMs are pharmacy benefit managers who …
manage prescription drug benefits for clients (health insurers, large self-insured employers, or Medicare Part D drug plans) with the specific intent to lower costs of drugs. PBMs negotiate with drug manufacturers and pharmacies to determine access to and cost of available drugs.
PBMs also process pharmacy claims, administer rebates, set up clinical programs, establish retail pharmacy networks, communicate with providers and patients, analyze drug interaction data, and provide mail order services
HMO (Health maintenance organization plan) generally
-Patients must go to providers, physicians and hospitals within the network (on the plan’s list)
-If you go outside the network, there will be no coverage, unless you have a point-of- service option in your plan that allows for out-of-network coverage where you pay a higher cost for services
-Usually must choose a PCP (primary care physician) and usually need a referral to see a specialist
PPOs ( Preferred Provider Organization plan )
No restrictions on providers, but members pay less for in network providers and pay
more for out of network providers
Don’t need to choose a PCP and usually don’t need a referral to see a specialist
With the increased flexibility of a PPO, why would someone choose an HMO?
It is usually cheaper; you generally pay more for insurance premiums with the PPO plan
Medicare Prescription Drug Improvement and Modernization Act of 2003
Established new Medicare Part D drug benefit
effective 2006
Created provisions for Medication Therapy Management (MTM)
what did the Affordable care act required a minimum set of MTM services (otherwise the quality of plans varied); what does the minimum services include?
An annual comprehensive medication review provided in person or with telehealth technologies (e.g., telephones, videoconferences) by a licensed pharmacist or other qualified provider
Follow-up interventions as warranted based on the findings of the annual medication review or the targeted medication enrollment and which may be provided in person or using telehealth technologies.
Medicare Part D plan sponsors must have a process to:
Assess, at least quarterly, the medication use of individuals who are at risk but not enrolled in the MTM program, including individuals who have undergone a transition in care (e.g., a hospitalization or stay in a skilled nursing facility), if the prescription drug plan sponsor has access to that information.
Automatically enroll targeted beneficiaries, including beneficiaries identified in the quarterly assessment.
Allow beneficiaries to opt-out of enrollment in the MTM program.
There are many different Medicare Part D Plans to choose from and they are by law required to cover all or substantially all of the drugs in six groups (referred to as “protected” classes of medications):
Antidepressants
Antipsychotics
Anticonvulsants
Antiretrovirals
Antineoplastics
Immunosuppressants
medicare part d tiers
In each plan, drugs are put in groups called tiers and the patient’s co-pay will be set at a certain level according to what tier the drug is categorized into
Tier 1 is the lowest co-pay level and Tier 4 is the highest co- pay
