Test 3 Flashcards
Medicare
subsidized insurance for the aged (65+), disabled, in need of kidney dialysis
100% federally funded
Medicare Part A covers
Hospital Insurance
- hospital care
- skilled nursing care
- hospice
Medicare Part A for Hospital Insurance characteristics include
high deductible and high cost sharing
non-voluntary, auto at 65 years old
funded by a pay as you go system (FICA tax)
Medicare Part A funding
FICA TAX employer and employee paid even split 1966- total 0.7% 2013 - total 2.9 % ACA - needed more funding so individuals over 200k threshold pay a higher amount that is not evenly split 2.35:1.45
Medicare Part B covers
Supplemental Medical Insurance
- physician services
- outpatient diagnostic tests (not prescription drugs)
- medical supplies
Medicare Part B for Supplemental Medical Insurance funding includes
premiums are heavily subsidized subsidized mostly by income tax (75%) insurance premium funds of 25% administered by the government not paid with FICA (payroll tax)
Part C (Medicare Advantage) consists of parts
- Enrolled in parts A and B
- D is optional and provided through a privately managed care insurance company
- nothing universal
Medicare Part C (Medicare Advantage) characteristics /funding include
subsidized by income tax revenue
pushed by GW Bush admin to push privitization
given by private provided by the government
2019: approx. 1/3 of medicare beneficiaries were on Part C
+ contracts admin work to private companies
- gov’t and insurance alignment coverage vs. profitization
MedicarePart D covers
Prescription Drug Benefits
Medicare Part D characteristics/funding include
began in 2006
voluntary program
premium paid is based on income
most subsidized by income tax revenue (75%)
premiums collected account for 25% of expenditures
Medicare Part D donut hole 2010
$310 deductible $311 - $2830: 25% coinsurance rate $2830 - $6400: no coverage > $6400: 5% coinsurance rate - ACA closed hole and eliminated by 2020
Motives for Medicare Part D Donut Hole
- majority of beneficiaries didn’t reach the hole
- incentive to not reach hole and control medical expenditures by decreasing the consumption of prescription drugs
Hospital Reimbursement Under Medicare (Part A) Cost Plus
-only A because nothing universal in C
initially, hospitals were reimbursed
with cost plus
cost plus = treatment cost + additional percentage
Hospital Reimbursement Under Medicare (Part A) DRG’s Early 80s
Diagnostic Related Group (DRG)
- hospitals are reimbursed a flat fee
- only based on the diagnosis of the patient not resources used
- upcoding problem: hospital diagnosing patients with more severe diagnosis
- still fairly effective and used today
Physician Reimbursement Medicare (Part B) initial
initially UCR - Usual Customary Rate (per geographic area)
- created incentives for physicians to inflate rate over time
Physician Reimbursement Medicare (Part B) Early 90s RBRVS
Resource-Based Relative Value Scale (RBRVS)
- takes every physician procedure + resources used = service with points
- considers time, effort, and resources necessary to produce physician service
- Medicaid reimbursed a flat dollar amount for each point
Physician Reimbursement Part B Medicare Access and CHIP Reauthorization Act (MARCA) 2019
(Merit Based MIPS and AAPM/ACO)
overturned Sustainable Growth Rate - fear of not servicing Medicare because would cut reimbursement
Merit Based Incentive Payment System (MIPS)
- outcome measures,quality of care measures, clinical improvement activity
- can result in bonuses/penalities, Medicare payment increases/decreases
-Advanced Alternative Payment Model (AAPM)
ie ACOs shared responsibility inc financial to lower costs and excess procedures
-incentives to keep savings
Balanced Budge Act of 1997 (?)
instituted sustainable growth rate, congress never implemented
offered 2 alternative ways MIPS and AAPM
Advanced Alternative Payment Model (AAPM)
Accountable Care Organizations (ACOs)
- have different types of providers
- receive a bundled fee for producing coordinated care to medicare beneficiaries
- eligible for bonus payments or penalitis based on performance and cost reductions
Medicaid (budget, meaning)
subsidized insurance for low income
- 1985 2.4% budget -> 2021 10% of budget
- administered by state and jointly funded by fed and state govt
Medicaid Pre-ACA minimum eligibility reqs
minimum eligibility requirements
- > low income single parent families
- > low income pregnant women
- > low income blind, aged &disabled
- reimbursement for providers is low
Medicaid Pre-ACA funding and est
- federal matching funds (50-75%) depending on state ability
2012: on average 17% of those with income less than FPL were eligible for Medicaid - signed into law 1965
- 1982: all states had Medicaid (AZ last)
CHIP (Children’s Health Insurance Program) who
- Child Medicaid
- provide coverage for children of low income families that do not qualify for Medicaid
- fed gov’t provides mathcing funds
- states have broad flexibility to set eligibility requirements
- median eligibility is 255% of FPL
CHIP take up
children that were previously uninsured took insurance
