Objective 4 - Government Programs

Question 1

Workers in the US who are not covered by Social Security

Answer 1

1. Federal employees hired before 1984
2. About 1/4 of the state and local government workers (those who are covered by plans that are comparable to Social Security)
3. A very small number of people who object to receiving governmental benefits on religious grounds
4. Railroad employees, who are covered by a program similar to Social Security

Question 2

Requirements for insured statuses under Social Security

Answer 2

1. Disability-insured status - requires between six credits (at young ages) to 40 credits (at ages 62 or older). Some credits mush ave been earned recently, as follows:
   a) For those required to have 20 or more credits, 20 credits must be from the last 40 quarters
   b) For those required to have between 6 and 20 credits, at least half must have been earned after age 21
   c) For those required to have 6 credits, all must have been from the last 12 quarters
2. Fully-insured status - requires credits equal to the worker’s age minus 22, with a minimum of 6 and a maximum of 40
3. Currently-insured status - requires 6 credits in the 13 calendar quarters ending with the quarter of death

Question 3

Eligibility of benefit amounts for Social Security disability and survivor benefits

Answer 3

1. Disabled-worker benefits
   a) Eligibility - must be disability insured and fully insured and be unable to engage in any “substantial gainful activity”
   b) Benefit amounts - calculated using essentially the same procedures used for retired-worker benefit amounts, using an assumed age of 62 and no early-retirement reduction factor
2. Survivor benefits
   a) Eligibility - family members may receive survivor benefits if the worker was either fully insured or currently insured at the time of death
   b) Benefit amounts - the worker’s primary insurance amount (PIA) computed using the standard procedures and assuming an age of 62. Survivors receive a percentage of the PIA:
   i) 75% for eligible children
   ii) Grading linearly from 71.5% at age 60 to 100% at normal retirement age for eligible widows or widowers
   iii) 82.5% for an eligible surviving parent, or 75% each for 2 parents
   (a family maximum applies, which is typically 175%)

Question 4

Individuals eligible for Medicare coverage

Answer 4

1. Aged - at least age 65 and eligible for Social Security or Railroad Retirement benefits
2. Disabled - entitled to Social Security or Railroad Retirement disability benefits for at least two years
3. End-stage renal disease (ESRD) - insured workers with ERSD, including spouses and children with ERSD
4. Some other aged and disabled individuals who pay mandatory premiums

Question 5

Types of Medicare coverage and funding

Answer 5

1. Part A - hospital insurance (HI)
   a) Eligible persons receive coverage automatically with no premium charge
   b) Funded through payroll tax rate of 1.45% of all earnings, with a matching employer tax
2. Part B - supplementary medical insurance (SMI)
   a) Requires a monthly premium ($99.90 in 2012, except higher for high incomes)
   b) Beneficiaries can decline coverage, but a premium penalty (10% per year) applies if coverage is elected at a later date
   c) Financed through general revenues (75%) and beneficiary premiums (25%)
3. Part C - Medicare Advantage
   a) Alternative to Parts A and B. Offered by private plans, which receive a capitation from Medicare, which varies by county and enrollee risk
   b) Typically offer lower cost sharing plus coverage for some services not covered under Medicare
4. Part D - covers most prescription drugs. Provided through private insurers. Funded through general revenues (74.5%) and premiums (25.5%)
5. Medicare Supplement - private insurance to cover out-of-pocket costs and some other benefits not covered by Medicare

Question 6

Services covered by Medicare Part A

Answer 6

1. Inpatient hospital - semi-private room and ancillary services and supplies
2. Skilled nursing facility (SNF) - semi-private room, meals, skilled nursing, and rehabilitative services after a related three-day inpatient hospital stay
3. Home health agency - services following discharge from a hospital or SNF
4. Hospice care - provided to terminally ill patients with life expectancies less than six months

Question 7

Medicare Part A cost sharing and coverage limits

Answer 7

Based on a benefit period, which starts at admission and ends 60 days after discharge from hospital or SNF. The dollar amounts are indexed. The amounts shown were for 2012.
Type of service / Cost-sharing / Coverage limits
-Inpatient hospital - $1,156 deductible per benefit period; $289 per day for days 60-90 each benefit period; $578 per day for days 91-150 each lifetime reserve day / 60 lifetime reserve days; No coverage beyond lifetime reserve
-SNF - $144.50 per day for days 21-100 of each benefit period / No coverage after 100 days each benefit period
-Home health agency - None / 100 visits per illness
-Hospice care - None / None
-Blood - Cost of first 3 pints of blood / None

Question 8

Services covered by Medicare Part B

Answer 8

1. O/P hospital (including emergency room)
2. Medical care by qualified health practitioners (including diagnostic tests, supplies, and durable medical equipment)
3. One-time initial wellness physical within 6 months of enrolling in Part B
4. Ambulance
5. Clinical laboratory and radiology
6. Physical and occupational therapy
7. Speech pathology
8. Outpatient rehabilitation
9. Radiation therapy
10. Transplants
11. Dialysis
12. Nome health care beyond that covered by Part A
13. Drugs and biologicals that cannot be self-administered
14. Certain preventative services (such as an annual flu shot and cancer screenings)

Question 9

Medicare Part B cost sharing

Answer 9

1. Calendar year deductible ($140 in 2012)
2. Coinsurance after the deductible (usually 20% of the Medicare-approved amount, but does not apply to clinical lab and certain preventative care services)

Question 10

Drug types excluded from standard Part D coverage

Answer 10

1. Drugs covered by Part A or B
2. Anorexia and weight loss drugs
3. Fertility drugs
4. Cosmetic drugs (including hair loss)
5. Drugs used to relieve cough and cold symptoms
6. Vitamins and minerals (except for prenatal vitamins and fluoride)
7. Over-the-counter drugs

Question 11

Approaches for improving Medicare solvency

Answer 11

1. Increase taxes
2. Reduce or eliminate some covered services
3. Increase Medicare cost sharing through higher deductibles and copays
4. Raise the eligibility age for benefits to age 66 or 67
5. Adjust reimbursement to providers of care
6. Adopt other initiatives to lower cost trend, such as accountable care organizations

Question 12

Medicare provider reimbursement

Answer 12

1. Hospitals - reimbursed on a prospective payment system basis using the diagnostic-related grouping (DRG) methodology. Paid a set amount to each admission (which encourages hospitals to provide services efficiently) based on the patient’s condition and the services provided.
2. Physicians - uses a complex fee schedule to assign relative values to services. Reimbursement equals the sum of area-adjusted unit value, multiplied by a nationwide conversion factor. Unit values for the procedures are based on:
   a) Work value - measuring the time and skill required
   b) Practice expense - reflecting the cost of rent, staff, supplies, equipment, and overhead
   c) Malpractice value - measuring the associated professional liability costs
3. Outpatient services - reimbursed on an outpatient prospective payment system known as ambulatory payment classification

Question 13

Categories of Medicaid-eligible individuals

Answer 13

1. Categorically eligible groups
   a) These groups include children, parents, or other caretakers with dependent children, pregnant women, individuals with disabilities, and seniors
   b) Individuals in these categories must also meet income and asset requirements (the minimum criteria is set by the federal government). For example, states must cover all pregnant women and children under age 6 with incomes below 133% of FPL
2. Medically-needy individuals - states often extend coverage to these individuals, who qualify when their medical expenses reduce income below defined limits
3. The ACA expanded eligibility to everyone under age 65 with income up to 133% of FPL (in states that choose to expand)

Question 14

Equivalence requirements for Part D employer group waiver plans (EGWPs)

Answer 14

1. Benefits must be at least as rich as standard Part D benefits
2. The deductible must be no greater than the standard Part D deductible
3. Catastrophic coverage must be at least as rich as standard Part D catastrophic coverage

Question 15

Types of Part D plans

Answer 15

1. Prescription drug plans (PDPs) - private stand-alone plans that offer drug-only coverage
2. Medicare Advantage prescription drug plans (MA-PDs) - plans that offer both prescription drug and health coverage

Question 16

Late enrollment penalty for Part D plans

Answer 16

1. Applies to those who do not sign up for Part D when they are first eligible
2. Is 1% of the base beneficiary premium for very month the person waited to enroll
3. Is paid every month for the beneficiary’s lifetime
4. Does not apply if the individual had creditable coverage through another source (such as an employer or retirement plan). Coverage is creditable if it is at least as god as Medicare Part D.

Question 17

Options provided by CMS to incentivize employers to participate in Part D

Answer 17

1. Retiree drug subsidy (RDS)
   a) To qualify for the subsidy, the plan must provide an actuarial attestation that it provides coverage at least as rich as Part D (gross test) and with a subsidy at least as great as the Part D subsidy (net test)
   b) The government reimburses the sponsor for 28% of prescription drug spending otherwise covered by Part D for drug costs between the cost threshold ($310 in 2011) and cost limi ($6,300 in 2011).
   c) Drug rebates are subtracted from the amount eligible for the subsidy
   d) Easiest and potentially most lucrative option, although the ACA eliminated the employer tax deduction for the subsidy as of 2013
2. Empoyer group waiver plan (EGWP) - was conceived to be superior to the RDS. Two options are:
   a) Direct contract EGWP - contract directly with CMS to become a PDP
   b) “800” series EGWP - outsource to a third-party PDP or MA-PD, who performs the administrative and financial functions of the plan
3. Coordinate benefits in a wraparound plan
   a) Employer plan fills in benefit voids that are not covered by Part D (eg. paying the deductible or a percentage of the coverage gap or total out-of-pocket costs)
   b) A concern with this option is that pharmacies may not be prepared to manage patients with two benefit plans (Part D and the wraparound plan)

Question 18

Advantages of using EGWP instead of RDS

Answer 18

1. Cost savings - savings are about 15-20% in RDS compared to 19-35% under EGWP
2. Minimal disruption to the membership - current plan design can usually be maintained
3. Tax obligations are treated equally between EGWP and RDS
4. Direct monthly subsidy is received from CMS
5. Governmental Accounting Standards Board Statements 43/45 liability is reduced
6. Part D benefit provides catastrophic coverage
7. Additional advantages of using an “800” series EGWP
   a) Administrative functions are handled by the third-party sponsor
   b) Risk avoidance - risk is shifted to the third-party sponsor
   c) The employer has no direct contract with CMS
   d) The third-party will handle compliance with regulatory issues

Question 19

Beneficiary cost sharing for the standard Part D benefit design

Answer 19

Drug cost range / Level / Beneficiary Pays:

• $0-$320 / Deductible / 100%
• $320.01-$2,930 / Initial coverage / 25%
• Until member reaches TrOOP of $4,700 / Coverage gap (“donut hole”) / 86% for generic and 50% for brand*
• After TrOOP / Catastrophic coverage / About 5%**
• Due to ACA, these percentages are gradually decreasing until they reach 25% for both brand and generic drugs in 2020
• *Greater of 5% or a copay of $2.60 for generics and preferred multiple source drugs or $6.50 for other drugs

1. TrOOP - true out-of-pocket cost
2. The deductible, initial coverage limit ($2,930), TrOOP, and catastrophic copays are indexed annually. The amounts shown here are for 2012.
3. Low-income beneficiaries have a different benefit design. For example, dual eligibles pay no premium, have no deductible, and pay only a small copay for drugs.

Question 20

Impact of regulations on the Medicare Advantage (MA) program

Answer 20

MA is the current name of this program wherein Medicare contracts with private plans to provide benefits to seniors and the disabled

1. The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 authorized the Medicare program to pay HMOs on a capitated basis. These HMOs were able to lower costs and use the savings to offer more comprehensive benefits than FFS Medicare, so these plans grew steadily
2. The Balanced Budget Act (BBA) of 1997 significantly reduced health plan payments. About half of the beneficiaries in Medicare health plans exited over the next few years.
3. The Medicare Modernization Act (MMA) of 2003 reignited enrollment by:
   a) Creating the Medicare Part D drug benefit
   b) Creating regional MA PPOs
   c) Creating special needs plans (SNPs)
   d) Dramatically increasing payment for MA plans
   e) Introducing competitive bidding and risk-adjusted payments
4. The ACA made dramatic changes to MA:
   a) MA plans suffered cuts of $136 billion over 10 years
   b) A new payment methodology was introduced, reducing county benchmark rates to between 95% and 115% of FFS Medicare rates
   c) Bonus payments were introduced for plans that achieve at least four stars under a new star rating system. High-quality plans will receive a bonus of 5% of the new benchmark payment rate, with certain counties being eligible for double bonuses. Rebates were also ties to quality ratings (described in a separate list)
   d) A minimum medical loss ratio standard of 85% was also imposed

Question 21

Types of MA plans

Answer 21

1. Coordinated care plans (see separate list for the types of coordinated care plans)
   a) These plans use a network of providers, which CMS must approve to ensure beneficiaries have sufficient access to covered services
   b) Other than in an emergency, beneficiaries mush use the network in order for the care to be covered.
2. Private FFS plans
   a) Enrollees can self-refer to any Medicare provider wiling to accept the plan’s coverage rules
   b) Providers are paid on a FFS basis at Medicare fee schedule rates and do not accept financial risk
3. Medical savings account plans
   a) These plans combine a high-deductible MA plan and the medical savings account
   b) The account is similar to commercial HSAs. But only Medicare can make a deposit into the account.

Question 22

Types of MA coordinated care plans

Answer 22

1. HMOs - are similar to commercial HMOs and represent the majority of all MA enrollments. They can offer a POS option to cover services out of network
2. PPOs - like commercial PPOs, they do not use gatekeepers, have larger networks than HMOs, and provide some coverage for non-contracted providers. Types include:
   a) Local PPOs - can choose which counties to operate in
   b) Regional PPOs - must serve all counties within their region. They are given more flexibility in meeting access standards.
3. Special needs plans (SNPs) - enrollment is limited to individuals with special needs. Most are offered by HMOs. Types include:
   a) Dual-eligible SNPs (D-SNPs) - for those eligible for both Medicare and Medicaid. They coordinate the benefits and requirements of those two programs.
   b) Institutional SNPs (I-SNPs) - for the institutionalized (such as a skilled nursing facility or psychiatric facility)
   c) Chronic care SNPs (C-SNPs) - for those with a severe or disabling chronic conditions (defined by CMS). Must include certain benefits beyond Medicare Part A and Part B services.
4. Religious and Fraternal Benefit Society plans
5. Senior housing facility plans

Question 23

Payment calculation for MA plans

Answer 23

1. MA plans submit bids to CMS each year, representing their projected costs to cover Part A and Part B services, net of cost sharing, plus administrative costs and profit.
2. The bid amount is normalized to a risk score of 1.0 and then compared to the benchmark. when a plan covers more than one county, the bid and benchmark are calculated as weighted averages of the county-specific amounts.
3. If the bid exceeds the benchmark, the plan must charge beneficiaries a monthly premium to cover the difference.
4. If the bid is less than the benchmark, the plans receive a percentage of the resulting savings as a rebate and must use this to provide additional benefits or pay beneficiaries’ Part B or Part D premiums. The rebate is 70% for plans with a rating of 4.5 or 5 stars, 65% for plans with a rating of 3.5 or 4 stars, and 50% for plans with a rating below 3.5 stars
5. CMS may require changes to the bid if:
   a) Beneficiary costs are increasing at an unacceptable rate
   b) The proposed profit margin is considered too high
   c) The benefit design is considered discriminatory, which could discourage enrollment of sicker beneficiaries
   d) The cost sharing design is not at least as generous as FFS Medicare

Question 24

Payment calculations for Medicare Part D plans

Answer 24

1. Part D plans submit bids to CMS each year, representing their projected costs to provide the standard Part D benefit package, net of cost sharing, plus administrative costs and profit
2. CMS then calculates the following:
   a) National average monthly bid = the enrollment-weighted average of all Part D bids received
   b) Base beneficiary premium = national average monthly bid * 25.5% / (1 - projected reinsurance payments to Part D plans / projected total claim payments to Part D plans)
   c) Direct subsidy = national average monthly bid - base beneficiary premium
3. CMS makes the following payments to plans:
   a) Risk-adjusted direct subsidy
   b) Low-income premium and cost-sharing subsidies for beneficiaries who qualify for financial assistance
   c) Reinsurance to cover 80% of members’ costs in excess of the catastrophic threshold
   d) Risk corridor payments
   i) The payment is 50% of actual costs that exceed project costs by between 5% and 10%, plus 80% of the amount exceeding 10% of projected costs
   ii) Conversely, the plan must pay CMS using those same percentages when actual costs are at least 5% less than projected costs
4. The plan must charge beneficiaries a premium equal to the difference between the plan’s bid and the direct subsidy

Question 25

Basic requirements for a health plan to be eligible for a Medicare contract

Answer 25

1. Be licensed as a risk-bearing entity to offer health insurance in the states in which it operates
2. Demonstrate financial solvency and a positive net worth
3. Offer premiums that do not exceed the actuarial value of Medicare cost sharing
4. Offer benefits and premiums that are uniform throughout the service area
5. Use Medicare-certified providers and demonstrate network adequacy, meeting CMS access standards
6. Meet minimum enrollment requirements: at least 5,000 members or, in rural areas, at least 1,500 members
7. Demonstrate an ability to administer the contract (eg. meet quality requirements, have a compliance plan, and address fraud and abuse)

Question 26

Election periods during which Medicare beneficiaries can enroll or disenroll in MA plans

Answer 26

In general, a Medicare beneficiary who has both Part A and Part B and permanently resides in the MA plan’s service area may enroll in the plan if the enrollment request is received during an election period

1. Annual election period - from Oct 15 through Dec 7, all eligible beneficiaries can join or switch plans for the current year
2. MA disenrollment period - between January 1 and February 15 of each year, members can disenroll from an MA plan and return to FFS Medicare. They can join a Part D plan to add drug coverage.
3. Special election periods - these center around certain events, such as when an individual moves, loses other coverage, gets Medicaid, or loses Medicaid or low-income subsidies
4. Initial coverage election periods - these allow individuals to enroll in an MA plan or a Part D plan beginning 3 months before they first become eligible for these plans
5. Open enrollment for institutionalized individuals - is continuous but only applies to individuals who move into, reside in, or moved out of institutions such as skilled nursing facilities and LTC hospitals. Individuals have the right to enroll in plans that allow it, but MA plans are not required to be open for this period.

Question 27

Situations resulting in involuntary disenrollment of MA plan members

Answer 27

An MA plan must involuntarily disenroll beneficiaries who:

1. Leave the service area permanently
2. Are incarcerated
3. Lose entitlement to either Part A or Part B

An MA plan may involuntarily disenroll beneficiaries who:

1. Commit fraud in enrolling in a plan or allowing others to use their enrollment cards to obtain care
2. Fail to pay premiums in a timely manner
3. Use disruptive or abusive behavior

Question 28

Marketing and sales rules for MA plans

Answer 28

1. Prohibited marketing activities include:
   a) Door-to-door solicitation
   b) Discriminatory marketing
   c) Misleading marketing or misrepresentation
   d) Giving monetary incentives as an inducement to enroll
   e) Completing any portion of the enrollment application for a prospective employee
2. Prior approval is required for all marketing and enrollment materials
3. Prospective enrollees must be given descriptive material sufficient for them to make an informed choice
4. Enrollees must be notified at least 30 days in advance of changes in membership rules and must be given a notice of change in benefits and cost sharing by September 30 of the year before the change
5. Plans can conduct “marketing or sales events to promote the plan and “educational events” that do not include sales activities
6. Plans must train and test all agents and brokers annually on Medicare rules and on details specific to the plans they are selling. CMS has established rules on compensation.
7. Plans must have a website or web page dedicated to each product, and must operate a variety of call centers to answer enrollees’ questions

Question 29

MA requirements related to access to care

Answer 29

1. Maintaining an adequate provider network, including minimum provider-to-enrollee ratios
2. Using the “prudent layperson” definition of what constitutes an emergency
3. Limiting copayments for emergency services to amounts specified by CMS
4. Covering out-of-area dialysis during an enrollee’s temporary absence from the service area
5. Specifying that the examining physician’s decision prevails regarding when a patient may be considered stabilized for discharge or transfer
6. Requiring plans to permit females to choose direct access to an in-network women’s health specialist for women’s routine and preventative health services

Question 30

Steps of the MA member appeals process

Answer 30

Appeals pertain to adverse decisions regarding coverage or cost

1. The determination by the organization within 14 days
2. Reconsideration by the organization within 30 days. And if that decision is adverse to the enrollee, a review of that decision by an independent review entity under contract to CMS
   a) These first two steps may require an expedited decision (within 72 hours) if needed due to an enrollee’s condition
3. Review by an administrative law judge (ALJ) for claims valued at $130 or more if the independent review entity’s decision is adverse to the enrollee
4. Review of the ALJ’s decision by the Medicare appeals council
5. Judicial review in federal court for claims valued at $1,300 or more

Question 31

Explanation of star ratings for MA plans

Answer 31

1. MA plans must report the following data to CMS, which it uses to create star ratings from one to five (five stars signifies an excellent-performing plan):
   a) HEDIS
   b) Consumer Assessment of Healthcare Providers and Systems (CAHPS)
   c) Health Outcomes Survey
   d) Plan information on contract performance measures
2. Plan ratings are reported at four levels (as of 2011):
   a) Overall rating for MA-PD contracts - average of Part C and Part D star ratings
   b) Summary level - the overall scores on the five Part C domains and four Part D domains
   c) Domain - groups of similar measures assigned a star treating based on an average of the individual measures
   d) Individual quality and performance measures (36 for Part C and 17 for Part D)
3. Organizations that fail to achieve at least a 3-star summary rating on Part C or Part D for 3 straight years is considered out of compliance with their Medicare contracts. CMS intends to terminate these contracts.

Question 32

Required elements of MA and Part D compliance programs

Answer 32

1. Written policies and procedures
2. Having a compliance officer (who reports to the CEO or other senior management) and a compliance committee (which provides periodic reports to the health plan’s governing body)
3. Training and education
4. Effective lines of communication
5. Enforcement of standards through well-publicized disciplinary guidelines
6. Monitoring and auditing
7. Corrective action procedures

Question 33

Enforcement actions CMS may apply to noncompliant MA plans

Answer 33

1. Administrative an intermediate sanctions - these are lesser actions that can be applied instead of termination or nonrenewal
   a) Reject applications
   b) For serious noncompliance: suspension of enrollment, suspension of marketing activities, and suspension of payment for new Medicare beneficiaries during the sanction period
2. Termination or nonrenewal - can be based on any one of 13 regulatory reasons for termination. These include failure to carry out the terms of the contract and failure to comply with prompt payment rules.
3. Civil monetary penalties - for example, $25,000 for each CMS finding where beneficiaries were adversely affected or could have been adversely affected
4. Exclusion from all federal programs - this generally follows conviction of a felony, misdemeanor, license revocation, or similar offense

Question 34

Barriers that affect access to care for Medicaid consumers

Answer 34

Despite a comprehensive benefit package (see separate lists), these barriers prevent many Medicaid consumers from receiving proper health care

1. Los physician payment rates - rates are much lower than even Medicare payments, leading many providers to not accept Medicaid patients
2. Lack of physician supply - providers often migrate to areas with higher income and lower unemployment, which does not align well with Medicaid populations
3. Social determinants - poverty and health literacy are the largest contributors to poor health
   a) Many people in poverty do not access needed medical services that are available to them. It also leads to poor living conditions, poor nutrition, and personal safety issues.
   b) Individuals with limited health literacy are less likely to use preventative care and are less likely to comply with prescribed treatments
   c) Other determinants include gender bias, racial bias, complex health care needs, and unemployment

Question 35

Medicaid federally-mandated services

Answer 35

1. Hospital (inpatient and outpatient)
2. Physician
3. Early and periodic screening, diagnostic, and treatment (for ages under 21)
4. Family planning
5. Federally-qualified health center
6. Freestanding birth center
7. Home health
8. Laboratory and x-ray
9. Nursing facility (for ages 21 and over)
10. Nurse midwife
11. Rural health clinic
12. Tobacco cessation counseling and pharmacotherapy for pregnant women
13. Non-emergency transportation

Question 36

Medicaid optional services most commonly covered

Answer 36

(each of these are covered by almost all states)

1. Medical or remedial care provided by licensed practitioners under state law
2. Intermediate care facility for individuals with mental retardation
3. Clinic services
4. Nursing facilities (for ages under 21)
5. Occupational therapy
6. Optometry and eyeglasses
7. Physical therapy
8. Prescribed drugs
9. Targeted case management
10. Prosthetic devices
11. Hospice
12. Inpatient psychiatric (for ages under 21)
13. Dental
14. Services for individuals with speech, hearing, and language disorders
15. Audiology

Question 37

Key characteristics of an effective Medicaid managed health care plan

Answer 37

1. A comprehensive network of providers who are responsive to Medicaid consumers
2. Effective utilization programs
3. Targeted and effective disease management programs
4. Targeted and effective case management programs for pregnancies, neonatal services, chronic illnesses, and childhood illnesses such as asthma
5. Excellent and effective call center support
6. Effective outreach that is both culturally and linguistically sensitive and addresses health literacy
7. Coordination of any service that may be carved out, such as behavioral care, pharmacy, and LTC
8. Capability for patient-centered medical home and health homes
9. Ability to work with accountable care organizations
10. Robust quality program to meet and exceed state requirements
11. Operational excellence for providers, such as claims payment accuracy and timeliness
12. Innovation with providers as it relates to use of electronic medical records and pay for performance
13. Compassion

Question 38

Elements to ensure success of managed LTC programs

Answer 38

1. Population - should include as broad a population as possible
2. Benefits - should include all Medicaid and waiver benefits, if possible
3. Program authority - the state should ensure the authorization for the program does not impose participation limits
4. Program design - for example, can use personalized evaluations for individuals to determine appropriate placement and allocation of services
5. Rate design - rates should be structured to incentivize appropriate utilization (eg. encourage health plans to place as few people in nursing homes as possible)
6. Clinical delivery - care managers develop comprehensive care plans and work with multiple providers to ensure reduced utilization of costly services
7. Identification and intervention - use analytic tools and face-to-face assessments to identify individuals who are at risk of needing services as early as possible, in order to effectively impact community placement
8. Comprehensive care management - the care plan should tie primary care to specialty care to home supports
9. Transition management - proper management of the transition from acute care to a new setting can help reduce the number of nursing home placement
10. Network development and increased access - networks must include nontraditional providers such as personal care, adult day care, and home-delivered meals

Question 39

Long-range financing challenges for the Medicare program

Answer 39

1. Income to the Hospital Insurance (HI) trust fund is not adequate to fund the HI portion of Medicare benefits. The HI trust fund is projected to be depleted in 2030, at which time payroll tax revenues are projected to cover only 85% of program costs.
2. Increases in Supplementary Medical Insurance (SMI) costs increase pressure on beneficiary household budgets and the federal budget. The SMI trust fund is expected to remain solvent because its financing is tied to projected future costs. But this will require increases in beneficiary premiums and general revenues contributions.
3. Increases in total Medicare spending threaten the program’s sustainability. Total Medicare expenditures were 3.5% of GDP in 2013. Under the baseline scenario, they are expected to grow to 6.8% of GDP in 2085.

Question 40

ACA provisions to address Medicare’s financial condition

Answer 40

1. Reductions to provider payment updates - to reflect productivity improvements
2. Medicare Advantage plan payments will be reduced gradually relative to FFS costs
3. Health care payment and delivery system improvements - for example, initiatives on bundled payments and accountable-care organizations
4. Increases in Medicare revenues - increasing the payroll tax, Part B premiums, and Part D premiums for those with higher incomes
5. Creation of the Independent Payment Advisory Board - to recommend changes to provider payments if the Medicare spending exceeds a target per capita growth rate