Mod 5 - Medicare and Medicaid Flashcards
FMAP
Federal Matching Assistance Percentage
Federally matched state Medicaid expenditures
Average is 60%
Mandatory Medicaid coverage groups
- Pregnant women and children under 6 with family income below 133% of the FPL
- Children 6-18 below 100% of the FPL
- Parents below states’ July 1996 welfare eligibility levels (often below 50% of the FPL)
- Elderly persons with disabilities who receive SSI
- Foster care and adoption assistance
Optional Medicaid coverage groups
- Pregnant women, children, and parents with income exceeding mandatory thresholds
- Elderly and people with disabilities at higher income thresholds
- Residents of nursing facilities (long term care) with income below 300% FPL
- Home health care waivers
- “Medically needy”
Medicaid is administered by ______ with _______ oversight
Medicaid is administered by states with CMS (i.e., federal) oversight
Medicare Part A
- Inpatient hospital costs, skilled nursing facility stays, some home health visits, post-acute home healthcare, and hospice care
Medicare Part B
- Supplementary medical insurance
- Physician visits, outpatient services, preventive services, and some health visits
Medicare Part C
Refers to Medicare Advantage programs through which beneficiaries can enroll in a private health plan
Medicare Part D
Covers outpatient Rx drugs through private plans that contract with Medicare
Medicare definition
Social insurance program that helps to provide health and financial security for people ages 65 and older and younger people with permanent disabilities
Medicare eligibility
- You or spouse worked at least 10 years (40 quarters) in Medicare eligible employment (legal job)
- People with permanent disabilities who have received Social Security Disability Insurance (SSDI) for 24 months (even if not satisfied 40 quarters) (1972)
- People with end-stage renal disease (ESRD) (1972)
- People with Lou Gehrig’s Disease (ALS) as soon as start receiving SSDI payments (no 2 year waiting period) (2001)
Private Fee-for-Service (PFFS) plan
A Medicare Advantage (MA) plan, offered by a state licensed risk bearing entity, which has a yearly contract with CMS to provide beneficiaries with all their MCR benefits, plus any additional benefits TBD by company
Preferred Provider Organization (PPO)
A managed-care network consisting of medical professionals and facilities, such as primary and specialty physicians, hospitals, and other healthcare pros, who contract with insurance providers to render services to subscribers
Health Maintenance Organization (HMO)
A network or organization that provides health insurance coverage for a monthly or annual fee. An HMO is made up of a group of medical insurance providers that limit coverage to medical care through doctors and other providers that are under contract.
National Federation of Independent Business v. Sebelius (2012)
Maintained ACA Medicaid expansion, BUT:
- limited the government’s authority to enforce it
- made it effectively optional for states
Number of states where ACA Medicaid expansion has not been adopted
12: WY, TX, WI, KS, MS, AL, TN, NC, SC, GA, FL
