Quiz Public Health Policy Flashcards
What is Medicare part A?
Enrollment is mandatory
Traditional Medicare
Covers:
Inpatient hospital care: For 1-60 days, you pay a deductible; for 61-90 days, you pay coinsurance.
Hospice Care: No cost
Skilled nursing facility: Cost sharing 1-20 days $0, 21-100 days: co-insurance
Long-term care is not covered.
Who is eligible for Medicare?
Everyone must be a U.S citizen
-Someone who is over 65 and qualifies for Social Security Benefits-Can be their earnings or spouse’s earnings
Disability: Someone who qualifies for social security disability income and has been receiving benefits for at least 24 months. Qualifying dx are end-stage renal disease, Lou Gehrig’s disease, and ALS.
Gets you Medicare part A and eligibility for Medicare Part B C D
How is Medicare Part A Funded by the government?
Medicare Part A, also known as the Hospital Insurance Trust Fund, is financed by:
Mandatory 2.9% payroll tax (covers 90%): Employees pay 1.45% for incomes up to $200,000 individual/$250,000 couple
2.35% for incomes over $200,000 individual/$250,000 couple
Remaining 10% covered by:
Taxation on SSI benefits, premiums for those ineligible for Part A, and interest earned on hospital insurance trust fund.
What is Medicare Part B?
Enrollment is voluntary
Traditional Medicare
Cost Sharing: 20% coinsurance after deductible is met.
Coverage: Physicians services (including in a hospital). Outpatient services, DME, drugs administered by a physician (lidocaine, chemotherapy, specified preventative services (vaccines and screenings), home health visits.
How is Medicare Part B Funded?
Supplemental Medical Insurance Fund is financed by:
Federal tax revenue (73%)
Monthly premium (24%): in 2023, it was $164.90 per month minimum. A 10% penalty for each eligible year but not enrolled will be added to all future months. Higher premiums for higher incomes (over $85,000/$170,000), Annual deductible ($226 in 2023)
Cost sharing
What is Medicare Part C?
Medicare Part C, also called Medicare Advantage, is a managed
care (or capitated) plan.
* Medicare pays a set amount of money to a private insurance company to
cover beneficiary care.
* Part C enrollment is voluntary, but restricted to those eligible for
Parts A and B.
* Eligible beneficiaries may enroll in either traditional Medicare
(Parts A and/or B) or Medicare Advantage.
How is Medicare Part C structured?
Plans set up by insurance companies must be equivalent to traditional Medicare fee-for-service
Each plan must cover at least all things covered by Parts A and B
Cost-sharing requirements depend on the plan
out-of-pocket spending is limited to $4972 in network 9245 out-of-network
Usually offers additional benefits such as hearing, dental, and vision.
Restricts providers (networks) and requires authorization for some services.
How is Medicare Part C Funded?
Financed by:
* Hospital Insurance Trust Fund (42% of Medicare Advantage
spending on parts A and B benefits in 2021)
* Supplemental Medical Insurance Fund (for Parts B and D
benefits)
* Medicare Advantage (MA) cost sharing, deductibles, and
premiums (equal to Part B premiums)
* Payments to MA averaged 106% of FFS (fee for service) in 2021
What is Medicare Part D?
Medicare Part D was created by the Medicare Modernization Act of 2003 and went into effect in 2006.
Penalty if you do not enroll when eligible and do not have equivalent coverage.
Covers outpatient prescription drugs
* Federal guidelines for minimal formulary requirement
* Variation in plan design, covered drugs, utilization management
* Coverage required for immunosuppressants, antidepressants,
antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics
Monthly premiums vary according to the plan. Some people are covered through employer or union plans.
How is Medicare Part D paid for?
Part D spending increased from $93 billion in 2020 to $95.9 billion
in 2021, 14% of Medicare spending
* Part D is financed by:
* General revenues (74%)
* Beneficiary premiums (15%)
* State contributions (11%)
* Beneficiary premiums covered about one-fourth of drug coverage
Source
What was the purpose of the independent payment advisory board?
The Independent Payment Advisory Board (IPAB) was created by the Patient Protection and Affordable Care Act (ACA) of 2010 to help control the growth of Medicare spending:
Purpose
The IPAB was intended to make recommendations to Congress and the Administration to reduce Medicare spending if it exceeded specific targets. The goal was to achieve savings without affecting the quality or coverage of Medicare. The IPAB could have recommended policies to improve care at lower costs, such as coordinating care, reducing waste, and prioritizing primary care. However, the IPAB was prohibited from recommending policies raising taxes, increasing premiums, restricting benefits, or rationing care.
Identify the major financing and spending challenges facing Medicare?
Prescription drug costs, moving from volume-based (sustainable growth rate) to quality-based system (merit-based incentive)
Funding Medicare is challenging as population who will need coverage grows.
Who is eligible for Medicaid?
Medicaid eligibility is based on:
* Income
* Assets
* No asset limit for eligibility based on low income
* State option for eligibility based on old age or disability
* State resident
* Citizenship/immigration status
* Legal immigrants with qualified status generally eligible
after five years in the United States
* State option to cover pregnant people and children who
are legal immigrants with less than five years of residency
What did NFIB v. Sebelius (2012) find?
26 states sued to challenge the constitutionality of the
ACA Medicaid expansion
* In a 7:2 decision, the Court found that the Medicaid
expansion was unconstitutionally coercive because states
did not have adequate notice to voluntarily consent to this
program change, and all of a state’s existing federal
Medicaid funds potentially were at risk for noncompliance
* Consequently, Medicaid expansion is a state option
States decide whether or not they want to expand Medicaid and get help to pay for it from the federal government or if they just want to keep the same old medicare system that they have.
Ten states have not expanded: Texas, Wyoming, Kansas, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, Florida, and South Carolina.
What do the federal guidelines say Medicaid must cover?
- Physician services
- Lab and X-ray services
- Inpatient hospital services
- Outpatient hospital services
- Early Periodic Screening, Diagnostic, and Treatment (EPSDT) (birth through age 21)
- Family planning
- Federally qualified health centers (FQHC) and rural health clinic services
- Nurse-midwifery
- Certified nurse practitioner
- Nursing facility
- Home health for those in nursing facilities
