Medicare and Medicaid

What part of Medicare pays for care provided to patients in hospitals, hospices, and home healthcare programs

Part A: Hospital Insurance

what part of Medicare provides coverage for physicians’ services, outpatient hospital care, and other ambulatory care services

Part B: Supplementary Medical Insurance

which part of Medicare expanded the ability to participate in a wide variety of private health plans, including HMOs and PPOs

Part C: Medicare Advantage

what happens in Part C: Medicare Advantage

Medicare will pay a different insurance company to handle the bills, bills don’t get sent to Medicare. Medicare privately contracts with other companies to handle patients.

which part of Medicare is when the the prescription drug, improvement, and modernization act of 2003 established a new prescription drug benefit

Part D : prescription drug benefit

you get part A: hospital insurance when you are

65 years old

you don’t have to pay a premium for part A if you are a

• US citizen and you or your spouse worked 10+ years in Medicare-covered employment

• receiving or eligible to receive benefits from Social Security or Railroad Retirement Board

• had Medicare-covered government employment

special circumstances that might qualify someone for Part A: hospital insurance

• disability benefits from Social Security or Railroad Retirement Board for at least 24 months

• no waiting period for ALS or end stage renal disease (ESRD) requiring dialysis or transplant

people who have part B are also eligible for part A and

pay a premium

(most people have both A and B)

people who have part C: Medicare advantage plan are also eligible for

part A

choose from approved MCO and may need to pay a premium

people who have part D are also eligible for part

A

must pay a premium

where does revenue for Medicare come from

payroll taxes

premiums

who administrates Medicare

Centers for Medicare and Medicaid Services (CMS)

US Treasury

Social Security administration

who determines reasonable charges for covered services to reimburse providers

CMS Centers for Medicare and Medicaid Services

Part A: inpatient hospital care covers all emergency care, but not

hospitalizations while in other countries

how does the blood deductible work (part A)

patients must pay for the first 3 pints of blood used each year

Part A covers ____ days of medically-necessary inpatient care per benefit period

90

In part A, each patient has a lifetime reserve of ____ days used if hospitalization exceeds 90 days in each benefit period

60

in part A what is the lifetime limit of inpatient psychiatric hospitalization not provided in a general hospital

190 days

Part A skilled nursing facility SNF care is limited to

100 days per benefit period

must be preceded by at least a 3 day hospitalization and within 30 days of discharge

what services are covered in plan B

• physician services in office, nursing facilities, home settings

• outpatient hospital services

• preventative services

• limited care by chiropractors, optometrists, podiatrists, dental surgeons

what services are not covered by part B

routine physical and vision exams

hearing aids

routine dental care

part B cost sharing involves a monthly premium, nominal annual deductible, and a co-insurance of

20%

Medicare participating physicians agree to accept only what

Medicare pays

If physician does not accept assignment

patients can be billed for the difference

(balance billing)

The Part C advantage plan must provide minimum of a

traditional Medicare benefit, excluding hospice care, without imposing any other out-of-pocket costs

if the plan is cheaper, Part C must pass on the savings to the beneficiary by

lower premiums or cost sharing

or return it to CMS

how is Part D covered while in traditional Medicare

enrolling in free-standing prescription drug plan (PDP)

How is Part D covered for part C

joining a Medicare Advantage plan that includes a PDP (MA-PD)

what are the 4 types of coverage for part D

Annual deductible

initial coverage phase

coverage gap phase

catastrophic coverage

For Part D, there are subsidies available for

low and limited income beneficiaries (LIS)

For part D, there are premium and deductible waivers and copayments are nominal with

generics < brands

covers most FDA approved prescription drugs

medicare part C and D plans get star ratings based on

good patient outcomes

patient surveys of satisfaction

ease of access to health care

markers of quality processes

Reimbursements to plans are tied to

star ratings

Medicare pays for _________ of the average beneficiary’s health care bills

less than half

Medigap is a private plan that covers

many of the charges not covered by Medicare

most basic Medigap policy (plan A) covers

co-pays for days 61-90 of inpatient hospitalization

co-pay for lifetime hospital inpatient reserve

100% of Medicare-eligible hospital costs after all Medicare benefits are exhausted

3 pint blood deductible

Medicare Part B co-insurance

legislation for Medicaid

Title XIX: grants to the states for medical assistance programs

SSA was passed in 1965

Medicaid was expected to be a temporary measure until universal health insurance passed but

Nixon won in 1968, stalling the universal health insurance movement

what act removed automatic eligibility for individuals who received cash welfare through Aid to Families with Dependent Children (AFDC)

Personal Responsibility and Work Opportunities Act of 1996

what did the Personal Responsibility and Work Opportunities Act of 1996 do

cut link between Medicaid and cash welfare

replaced AFDC with Temporary Assistance for Needy Families program

allows families to receive cash welfare for no more than 5 years

Since Medicaid is a joint state-federal program,

states have flexibility to determine criteria within federal guidelines

Medicaid eligibility is

complex, state-specific, and changes frequently

three broad groups may be covered by Medicaid

1. mandated categorically needy

2. optionally categorically needy

3. medically needy

who is mandated categorically needy

• families below a state-determined limit on income

• child deprived of parental support or care due to death, absence, incapacity, or unemployment

• individuals receiving cash assistance through social security income

• pregnant women and kids under 6 below certain income

• <19 below federal poverty level

• qualified Medicare Beneficiaries below certain income

Who is optionally categorically needy

• determined by states

• do not meet mandated requirements, but share certain characteristics with the group

• must receive SAME BENEFITS as mandated group

Who is medically needy

• optional category; determined individually by states

• Medical expenses reduce net income to below thresholds

• used mostly to grant eligibility to institutionalized persons who incur extremely large medical expenses

• like NURSING FACILITY PATIENTS

states must operate Medicaid programs to 3 general requirements

1. statewideness

2. freedom of choice

3. comparability of services

statewideness

in effect throughout state without variation

freedom of choice

obtain covered services from any qualifying provider

comparability of services

services equal for all beneficiaries

under the SSA, CMS can grant 2 types of waivers (experiments to try to save on Medicaid without hurting anyone)

section 1115

section 1915b

section 1115 is a

5 year demonstration waiver for innovative ideas

must be budget neutral

mostly have been managed care demonstrations

section 1915b targets

only current beneficiaries (will not expand eligibility)

who is using the most cost for Medicaid

children

but nursing home residents need it most

Medicaid spending is mostly for

the elderly and people with disabilities

Medicaid is actually an optional program, it is

not required of the states by the federal government

the federal portion of Medicaid program costs (Federal Medical Assistance Percentage) is determined by

comparing a state’s mean per capita income to the national average; max. 83% min 50%

(people argue that NY should have more help from the capital bc the avg income in NY is high from a small wealthy population)

many states have Medicaid recipients contribute to the cost of their health care by

deductibles, co-pays, or co-insurance

over 80% of states had copayments for

prescription drugs, most $0.50 to $3.00

nearly half of all Medicaid spending is for payments to

managed care organizations (MCOs)

what did the Patient Protection and Affordable Care Act 2010 (ACA) do

expand access to healthcare services

• individual mandate

• tax penalty for those who don’t enroll in a health plan (repealed)

creates state-based or federal health insurance exchanges

Medicaid expansion

Dependent coverage for adult children to age 26

Medicaid expansion states decided to

give more people Medicaid health care by challenging the limits

other states decided not to expand Medicaid coverage,

they’ll handle it without federal help