Miscellaneous 1 Flashcards
“Pendelum Effect” between the Medicare program & MA plans
~Republicans - free markets & competition
~Democrats - regulation & accountability for MA plans
Rx - coverage is considered creditable if..
it is at least as good at Medicare Part D
2 special Part D groups
~dual eligibles
~limited-income beneficiares
PDPs (prescription drug plans) defined as:
~must offer “standard benefit”
~may offer supplemental benefits - “enhanced benefits”
~can be flexible in plan design
~must follow marketing guidelines
those who benefit most from Part D
~no current drug insurance
~those who qualify for low-income subsidy assistance
~patients in MA with no drug coverage
~those who spend > $800 per year on Rx
MSP applies if the member has
Medicaid or a commercial health plan
Rx - coverage is considered creditable if it passes the
gross test
The ACA added the ________ for Medicare part D
Coverage Gap Discount Program
True or False
Employer Group plans do not submit part D bids
True
Medicare Supplement plans are filed with who?
state insurance departments
cost of employer groups relative to individual Medicare beneficiaries
substantially lower
For Rx benefits, employers or unions can provide benefits to Medicare eligible beneficiaries in the following ways:
- EGWP from 3rd party (800 series)
- primary coverage without a retiree drug subsidy (RDS)
- primary coverage with an RDS that offsets plan costs
- direct PDP contract with CMS & administering the plan directly
Which states provide disability wage replacement to workers
~California ~Hawaii ~New Jersey ~New York ~Rhode Island
social security - OASDI acronym
old-age, survivors, & disability insurance
level of utilization for Medicaid enrollees compared to commercial usue
significantly higher, particularly for the aged, blind, & disabled recipients
source of Medicaid funding
- Federal Government: 50-73% for each state
- state budgets
- federal government covered all of expansion costs til 2016, phased down to 90% by 2020
Impacts of ACA on Medicare Advantage
- Introduced payments based on quality measures (star rating)
- Minimum Loss Ratio of 85%
- Reduced benefits/ funding & increased premiums
Medicare Advantage - if a bid is over the benchmark..
member pays a premium
CMS - HCC.
What is it and 2 characteristics.
~risk adjustment methodology for MA-PD
~additive for multiple conditions
~uses IP, OP, age, sex, & eligibility status
Medicare Advantage - if the bid is below the benchmark..
the plan keeps a % of the difference to increase benefits or reduce cost sharing or premiums. rest of % is kept by CMS
Medicare Advantage started in what year?
1984 with the Tax Equity & Fiscal Responsibility Act (TEFRA)
Medigap policy many not be sold to beneficiaries enrolled in ___________
a Medicare Advantage Plan
when did Medicare Part D become available
2006 under the MMA (Medicare Prescription Drug, Improvement, & Modernization Act)
Funding & cost challenges Medicare & Medicaid face
- rising health care costs
- increasing enrollment
- longer life expectancies
