Lecture 29- Insurance, Medicare, and Medicaid

Distribution of types of insurance coverage (201)

53.3% Employer insurance, 16.3% Uninsured, 15.9% Medicaid, and 14.5 Medicare

Most common type of employer-based plans

PPO>HMO> POS>HDHP/SO>conventional

Preferred Provider Organization (PPO)

health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. Pay less if use providers belonging to the network

Health Maintenance Organization (HMO)

insurance plan that usually limits coverage to care from doctors who work for or contract with the MO; won't cover out-of-network care except in emergency; may require you live or work in its service area to be eligible for coverage; more restrictive

Point of Service (POS)

pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network; require a referral from PCP to see a specialist

High Deductible Health Plan (HDHP)

health plan that combines high deductible insurance and a funding option to pay for patients out of pocket expenses up to the deductible (combined with health savings account)

Conventional insurance plan

the insured person pays for a doctor visit and is then reimbursed by the insurance company for the entire cost of the visit; not as common

Deductible

Amount you must pay before you begin receiving any benefits from your insurance company

Coinsurance

your share of the costs of a covered health care services, usually calculated as a portion of the allowed amount for the service

Co-pays

A fixed amount you pay for a covered health care sercice, usually when you get the service; amount can vary by the type of covered health care service

Vision coverage

health benefit that at least partially covered vision care like eye exams and glasses

Highest percentage of uninsured individuals fall into what income range

32% have less than 25,000; as income increases then amount of uninsured individuals goes down

Age and uninsured proportion

Younger adults are disproportionately uninsured (25-34); >65 is very low uninsured

Vision insurance vs. dental insurance (2015)

47% had dental coverage and 26% had vision coverage

Majority of people who had problems paying medical bills had what insurance

Employer sponsored private insurance

Center for Medicare and Medicaid Services (CMS)

The Heath & Human Services (HHS) agency responsible for Medicare & parts of Medicaid.

Vision services typically covered by medicare

glasses after cataract surgery, diabetic eye exams, other medical exams

Medicare

insurance program covered individuals 65 and older, younger people with permanent disabilities (ESRD, ALS)

Prior to 1965, percent of 65+ without insurance

At least half

Expansion of Medicare

1972 for End Stage Renal Disease

2001 for ALS

Total federal spending for medicare

12% for medicare

People covered by medicare percentages based on different SDOH

47% below 200% FPL and 44% with 3+chronic conditions

Traditional Medicare Fee for Service

Part A and Part B

Medicare Part A

Hospital insurance-inpatient hospital services, skilled nursing facilities, home health, and hospice care; no premium requirement

Medicare Part B

medical insurance (most relevant for vision); physician, outpatient, home health, preventive services; pay premiums

Medicare Part C

Medicare Advantage; private health plan that pays for all benefits under Part A, B and often D; can enroll in HMO, PPO, or private FFS; required to use any extra payments to provide additional benefits to enrollees

Medicare Part D

prescription drugs; established by Medicare Modernization Act of 2003

Paying for Medicare Part A

2.9% tax; employers and workers generally split it

Premiums

the amount that must be paid for your health insurance paid by you and/or your employer monthly, quarterly, or yearly

Funding for Medicare Part B

optional and funded through general Medicare revenues and beneficiary premiums

Percent enrolled in Part A and Part B

95%

Funding for Medicare Part C

monthly Part B premiums and often an additional premium paid to the private plan

Funding for Medicare Part D

general revenues, beneficiary, premiums, and state payments

Doughnut Hole for Medicare Part D

area where the beneficiary are responsible for all of the drug costs between 2800 and 6400

10% of FFS Medicare Beneficiaries account for

About 60% of the medicare spending (chronic conditions)

Projection for medicare spending for all categories by 2030

spending is increasing significantly for all the parts

Spending for beneficiaries

Out-of-pocket cost is going up and will continue to go up

Federal Spending on federal Medicaid

8%

Medicaid funding

jointly funded by state and federal

Medicaid

income based; states have flexibility and can choose what is covered; covers a wide range of individuals (specifically pediatric population)

Cost sharing

share of costs not covered by your insurance that you pay out of your own pocket

ACA Medicaid expansion

138% of FPL; expanded coverage to more adults who weren't adults but met income thresholds

Medicaid services covered

inpatient hospital services, outpatient hospital services, lab and x-ray, skilled nursing home, physicians, home health services, early and periodic screening, diagnosis, and treatment (EPDST) for individuals under 21

EPDST

eligible children receive eye screening and if necessary a follow-up full exam and treatment services including eye glasses

Does Ohio have medicaid vision benefit?

Yes; copay of $2 and $1 for follow up; exam every 12 or 24 months

Children's Health Insurance Program (CHIP)

provides health coverage to nearly 8 million children in families with incomes too high to qualify for medicaid, but can't affod private coverage

ACA 3 primary objectives

1. Make affordable health insurance available to more people

2. Expand Medicaid program to cover all adults with income below 138% of the FPL

3. Support innovative medical care delivery methods designed to lower the costs of health care

Number of states that implemented Medicaid expansion

38 states and DC

Marketplace

a resource for people where they can learn about their health coverage options, compare health insurance plans based on cost, benefit and other important features and choose a health care plan and enroll in coverage

Essential Health Benefits of ACA

10 categories of services that must be covered: ambulatory, emergency, hospitalization, maternity and newborn, mental health, prescription drugs, rehab, laboratory services, preventive and wellness, pediatric services (eye care is covered)

ACA impact on uninsured

dropped the uninsured rate drastically but still not 0; insurance is still not affordable (becoming more and more unaffordable)