Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PHRM 849 > Update on Healthcare Financing and Coverage > Flashcards

Update on Healthcare Financing and Coverage Flashcards

1
Q

Describe the history of healthcare financing, insurance, government healthcare funding in the US.

A

Before insurance - patients expected to pay all health care costs out of their own pockets.
costs were low in the past compared to today bc US health expenditure as a % of GNP was way less (5%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

1920s

A

some hospitals offered services on a pre-paid plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

1929

A

the first employer-sponsored plan was created by teachers in Dallas, TX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

1935

A

Social Security Act – no health coverage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

WWII

A

employer-sponsored plans as a benefit dramatically
expanded as a direct result of wage controls

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

1946

A

Hill Burton Act – hospital construction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

1948

A

President Truman proposes national health insurance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

1954

A

tax deduction for employers in the Revenue Act

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Entire health insurance system was built on the

A

employer sponsored model
– A system for the retired (Medicare) 1965
– A system for the poor (Medicaid) 1965
– A system for the self-employed who had to buy insurance on their own through exchanges (ACA) 2010

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe the role of the ACA and the American Rescue Plan in expanding healthcare coverage to the uninsured in the US.

A

goals of the affordable care act:
* Improve Accessibility to Coverage
* Decrease number of uninsured
* Improved efficiency of providing care
* Improve Quality of Care
* Decrease Cost of Care
taxpayers did not like the ACA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

30 day readmission penalties

A
  • Historically 20% of Medicare patients are readmitted within 30 days
  • Review of the data indicates 75% of readmission are preventable
  • Savings to Medicare could be $12 billion/year
  • ACA penalizes hospitals for excessive readmission
    rates (3% in 2016)
  • Current diagnosis tracked: AMI, CHF, Pneumonia,
    Knee/Hip Replacement, and COPD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

History of medicare

A
  • Lyndon B. Johnson, president from 1963-1968, made passage of Medicare his top legislative priority
  • House vote: 307-116; Senate vote: 70-24
    – Medicare was also a priority of JFK but lost by 4 votes in 1962.
  • President Harry Truman and his wife Bess were presented with the first two Medicare cards.
  • Medicare and Medicaid were enacted as Title 18 and Title 19 of the Social Security Act.
    – Signed into law on July 30, 1965
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

History of medicaid

A

– Begins January 1, 1966
– Health insurance for the poor and medically indigent of all ages.
* Inpatient; Outpatient;
* Not required - last state to implement – AZ in 1982
– Federal-State partnership program.
* Matching funds based on state per capita income - 50-83% (now up to 90%)
* Federal standards for services
* Managed by state govt
* Wide variation in the quality and range of services in various states.
developed into important aspect of nation’s social welfare program

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Medicaid milestones

A

– 2014:
*ACA goes into affect expanding Medicaid eligibility for states that choose to opt in.
*Allows people with income up to 138% of FPL to qualify. ($17,775; $36,570 –family of 4)
*In 2022, > 50% of the nation’s uninsured live in states that have opted out of the expanded program.
*ACA and beyond: Healthcare and especially Medicaid has become somewhat of a political football.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Medicaid is comparable to ______ for access to care

A

private insurance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Medicaid per enrollee spending is significantly greater for

A

the elderly and individuals with disabilities compared to children and adults

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe who is eligibility for Medicare enrollment.

A

Medicare: begins july 1, 1966
Health insurance for the elderly (≥65yo)
* Disabled
* People of all ages with End-Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease); 19 million initially enrolled, no dental or eye benefits, no drug benefit for outpatients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe who is eligibility for Medicaid enrollment.

A
  • Low-income families who meet certain state requirements. < 138% of FPL in IN
  • Infants born to Medicaid-eligible pregnant women.
  • Children <6 yo and pregnant women with incomes < 138% of FPL (varies by State - <158% in IN)
  • Pregnant mothers are covered 12 months
    after the pregnancy ends.
  • Certain Medicare beneficiaries.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Hoosier healthwise

A

children and pregnant women

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Hoosier care connect

A

> 65 not eligible for medicare; blind; disabled

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Traditional medicaid

A

> 65 eligible for medicare; LTC; home or community based waiver services

22
Q

Healthy indiana plan

A

low income adults 19-64 with income < 138% FPL

23
Q

National enrollment for Medicaid

A
  • Mandatory Services: LTC, Hospital, Physician, Home Health, Prenatal care, Family
    planning services
  • Optional Services: Pharmacy, Dental, ICF for mentally retarded; Mental health rehab
  • Enrollment: ~85 million covered by Medicaid + CHIP; Assist 60% of all nursing home residents; Assist 40% of all childbirths (38% in Indiana)
24
Q

National eligibility Medicaid

A
  • 1/3 of all children are insured through
    Medicaid.
  • 60% of low-income children insured through Medicaid
  • While children are eligible for dental coverage, few dentists participate.
  • ACA: Provides eligibility for most low-income adults
    <65 with incomes <138% of FPL; Fed Gov pays 100% of expansion cost 2014-16, then declines to 90% in 2020?
25
Q

Medicaid reimbursement is

A

100%

26
Q

Who will contribute to higher medicare enrollment

A

an aging population

27
Q

Describe the coverage of the different parts of Medicare.

A

Part A, B, C, D
spending on physician services and other part B services accounts for the largest share of medicare benefit spending

28
Q

Part A

A

hospital coverage
– covers hospital costs
– No premium costs
– SNF care – max 100 days
– Some home health care; hospice care

29
Q

Part B (medigap)

A

medical coverage
– Premium costs deducted from SS.
– covers physician costs – not required
– Medical supplies
– drugs admin in MD offices

30
Q

Part C (medicare advantage)

A

– Parts A + B + D (May cover broader list of services)
– Managed care (private insurance companies)

31
Q

Part D

A

prescription coverage
- drug benefit
- premium costs deducted from SS

32
Q

Enrolling in part A

A
  • Enrollment can begin about 3 months before 65th birthday; enrollees do not need to be retired.
  • You do NOT have to enroll as long as you have a comparable insurance plan.
  • Starts when you start receiving Social Security benefits.
  • Most people receive Part A for free.
  • Penalty for late enrollment – impact on part B.
33
Q

What is not covered by part B?

A
  • Long-term care
  • Dental care
  • Cosmetic surgery
  • Eye examinations for prescribing glasses
  • Routine foot care
  • Hearing aids and exams
  • Acupuncture
34
Q

General rules for meds - parts A, B, or D?

A

– Where it will be used: Used in the hospital (A), doctor’s office (B) or used at home (D)
– What it is for?: For example: oral methotrexate used for arthritis (D) or as immunosuppressive / cancer treatment (B)?
– How it will be used?: For example: Insulin for pump (B) or Insulin for syringe (D)

35
Q

Medigap - medicare supplement

A
  • Not administered through CMS, but standardized by Federal law
  • Picks up deductibles for Part A
  • Picks up deductibles and copays for Part B
  • Standard options in each state
  • Purchased through private companies. – Premiums vary - $24 to $3,200
36
Q

Explain the concept of Medicare advantage plans (Part C) and its advantages and disadvantages.

A

– Features similar to managed care plans on private market (premiums,
deductibles, networks, optional services)
– PAs very common
– Recently aggressively advertised with greatly expanded list of services.
total medicare advantage enrollment is increasing

37
Q

Features of advantage plans

A
  • Administered by private companies, but the beneficiary is
    still considered enrolled in Medicare.
  • Premiums or the costs of services (co-pays and deductibles) can be lower than they are in Original Medicare or Original Medicare with a Medigap policy.
  • They may offer extra benefits including vision and dental.
  • Some plans include prescription benefits and may be at a cost lower than in the stand-alone Medicare Prescription Drug Plans (Part D).
  • Coordinate your care, fewer choices, using networks and referrals potentially reducing cost of overall care.
  • Ease of billing.
38
Q

Medicare star rating system

A
  • Used by CMS to measure how well Medicare
    Advantage and Part D plans perform.
  • Plans are reviewed annually.
  • 1to 5
  • Rated on how well plans perform in the following categories:
    – Staying healthy; screenings, tests, and vaccines.
    – Managing chronic conditions.
    – Plan responsiveness and care.
    – Member complaints, problems getting services, and choosing to leave plan.
    – Health plan customer services.
39
Q

Medicare - Part D

A
  • The largest change in insurance processing in retail pharmacy history.
  • Millions who had no prescription drug coverage now had an option.
  • Not a single entity. Beneficiaries need to voluntarily enroll and select a plan. – Average monthly cost = $41
  • Run by private insurance companies, but CMS sets minimum standards.
  • Formularies for each plan are DIFFERENT
    – Not all Medicare approved drugs will be on formulary
  • Pharmacists can assist pts with their selection of plan.
    this program was never funded!
40
Q

Medicaid drug spending and rebates

A

more coming back in rebates than what was actually spent

41
Q

Work status of women on medicaid

A

most women covered by medicaid work outside the home

42
Q

If the 14 remaining states expanded to implement medicaid

A

70% of uninsured adults would become newly eligible for medicaid if they lived in 4 states - TX, FL, GA, NC

43
Q

A broken HC model?

A

we do not have a single payer system where everyone has the same level of coverage; how we pay for it is a way that makes it broken

44
Q

What makes up the largest percent of healthcare coverage

A

employer only insurance

45
Q

Who is uninsured

A

young, latinx/hispanic, poor, sicker, and living in the south
people with chronic health problems

46
Q

Majority of the federal budget goes to

A

social security

47
Q

Majority of state budget goes to

A

education

48
Q

Why do people need health insurance?

A

help pay for medical services that may be outside of my needs
because HC is expensive and uncertain

49
Q

American rescue plan

A
  • People up to 150% FPL can now get silver plan at zero premium and lower deductibles.
  • Premium subsides for people up to 400% of FPL.
  • Extended enrollment periods.
  • Premium subsidies for people with COBRA plans.
  • States can extend Medicaid coverage for post- partum women up to 1 year.
  • Incentives for more states to expand Medicaid coverage.
  • Subsidies for rural providers adversely impacted by COVID.
50
Q

American rescue plan - Rx provisions

A
  • Require the federal government to negotiate prices for some drugs covered under Medicare Part B and Part D with the highest total spending, beginning in 2026
  • Require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries, beginning in 2023
  • Cap out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024
  • Limit monthly cost sharing for insulin to $35 for people with Medicare, beginning in 2023
  • Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023
  • Expand eligibility for full benefits under the Medicare Part D Low-Income Subsidy Program, beginning in 2024

PHRM 849 (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions