Prof quiz 3 hints, part 1 Flashcards
Definition of a hospital
An institution with at least 6 beds whose function is to deliver pt svcs that include diagnostics and tx
Expenditure formula
E = P X Q
Expenditures = price x utiilization
Definition of insured (beneficiary)
An individual protected by insurance
Insurer definition
An insurance agency that assumes the risk
Underwriting definition
Evaluation, selection (or rejection), classification, and rating of risk
Definition of premium
Amt charged by insurer to insure against risk
What is risk rating?
The actuarial assessment of risk
Benefits definition
Svcs covered by an insurance plan
Details about MLR
MLR = % of premium revenue spent on medical expenses
The rest = administration, marketing, and profits
85% for large grp insurance plans
80% for individual/small grp insurance plans
How many tiers are there of marketplace plans?
4
What is the minimum value test?
At least equivalent to the Bronze plan offered through the exchanges
What is the affordability test?
Employer’s share of the premium for a single plan is less than or equal to 9.5% of the HH income
What are the three groups of Medicare beneficiaries?
65 yrs and older
Disabled entitled to social security
Those with end stage renal dz
What are the parts of Medicare?
A
B
C
D
What is Medicare part A
Hospital insurance
How is Medicare part A financed?
mandatory payroll taxes
Employer and employee pay equally into the Hospital Insurance Trust Fund
When are no premiums required for Medicare part A?
If a person or spouse has worked and earned 40 credits
Medicare part A benefits
90 days of inpatient hospital care per benefit period
Lifetime care of 190 days in a psych hospital
Up to 100 days of care in a Medicare-certified SNF subsequent to inpt hsopitalization
Home health care through a Medicare-certified agency
Hospice care
What is Medicare part B generally?
Supplemental medical insurance
Covers various outpt svcs
Means-testing and Medicare part B
Started in 2007
A higher income threshold triggers Income Relative Monthly Adjustment Amount (IRMAA)
Results in higher premium
What is Medicare part C?
Medicare advantage
Hx of Medicare part C
Began as Medicare + Choice in 1997 then renamed Medicare Advantage in 2003
-No additional svcs, but additional health plan choices
-To channel into managed care for Parts A and B
-Can choose to remain in original Medicare program
Aspects of Medicare part C
Pay additional premiums
Additional benefits
No need for Medigap
Lower out of pocket costs
What is Medicare part D?
Prescription drug coverage
What can enrollees choose between for Medicare part D?
Stand-alone plans for prescriptions only
Part C (all svcs through managed care)
Payment in Medicare part D
Requires payment of a deductible
Three levels of out-of-pocket costs after deductible in Medicare part D
Basic level
Coverage gap (doughnut hole)
Catastrophic level
What is another component of part D, that’s also a component of part B?
Higher income leads to paying more, IRMAA
Who does Medicaid finance?
Indigent as determined by each state (means tested)
Who are dual eligible beneficiaries?
Eligible for both Medicare and Medicaid
Full duals for Medicare and Medicaid
Qualified for all benefits under both Medicare and Medicaid
Partial duals for Medicare and Medicaid
Some of the costs paid by Medicaid
