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1

Who pays the MOST for health care?

3.3 trillion TOTAL

PRIVATE HEALTH INSURANCE (35%)

Medicare gray hair (21%)

Medicaid not paid (18%)

Out of pocket

2

Medicare

Gray Hair

Social security act of 1965

Entitilement program that provides insurance for:

ELDERLY PERSONS

Individuals with long term or perminant DISABILITY

3

Who does MEDICARE cover?

57.1 million enrolyees

Elderly 65>

Disabled persons <65
previously working / contribute to Social Security
SSDI (social security disability insurance) for >24 months

ESRD (end stage renal disease)

ALS (amyotrophic lateral Sclerosis = lou gherigs)

4

Medicare enrollment TRENDS

INCREASING OVER TIME

in 1975 = start covering nonelderly disabled people

5

CHARACTERISTICS of the Medicare Population

3+ CHRONIC Conditions = 65%

Income <23.5k = 50%

Savings <61.4k = 50%

Cog/mental impairment = 31%

Fair/Poor health = 27%

Etc

Long-term care / facility resident = 5%

6

4 parts of MediCARE

Part A = HOSPITAL INSURANCE = HI

 

Part B = Supplementary Medical Insurance = SMI

 

Part C = Medicare Advantage Program = MA

 

Part D = Outpatient RX DRUG BENEFIT

 

7

What does Part B cover?

Hospital Insurance

Covers INPATIENT care, 
short-term stays in SNFs (skilled nursing facilities)
hospice care / post acute home health care / blood

Benes pay (2018): 
no premium for nearly everyone
DEDUCTABLE = $1,340 per episode of illness (benefit period) for hospitilization
$0 for other services

8

What do Benes Pay for Medicare PART A

no premium for nearly everyone

Deductable = $1340 per epidose of illness for hospitilization

$0 for other services

Copayment = NONE for days 1-60 of hospital stay
335$/day for 61-90 & 670/day for days 91+

for SNF = skilled nursing facilities, 1-20 = free -> $167/day 21-100

small for hospice / 20% for DME / none for home health

9

What does PART B cover?

Supplementary Medical InsuranceOPTIONAL

OUTPATIENT hospital care

 Physician Visits 

Ambulance

 Labs / Medical Equipment / Diagnostic Tests

10

What do benes pay?

Part B

supplementary medical insurance --> outpatient / physician visits

Premium = $134/month (standard)
 is higher for those with gross income >$85,000 per individual
is lower for those with Social Security benefits

Deductible = $183 per year

Copayments / coinsurance, after deductible is met
 = 20% of medicare approved amount for services

0$ for home health + clinical labs

11

What is NOT covered under Original (A + B) Medicare plans?

Outpatient Prescription Drugs (with a few exceptions)

Deductibles / coinsurance / copayments

dental care / dentures

routine foot (orthopedic shoes)  / eye care (most eyeglasses)

cosmetic surgery / hearing aids / exams

SCREENING TESTS / VACCINATIONS / Physical Exams

12

What do MediGAP Plans Cover?

Need to have Both A + B to have mediGAP
Fills in what is NOT covered by parts A+B

MOST COVER:
Part A deductible / SNF co-insurance / Foreign Travel emergencies

Some Cover:
Part B deductible + excess charges / Preventative care + @home

13

What is a MEDIGAP PLAN?

Supplemental Policy sold by private insurance companies to fill gaps in the OG medicare plan coverage

10 standardized plan options ( A -> N)

Need to have Both A + B to have mediGAP
Fills in what is NOT covered by parts A+B

only 20%> of medicare benes had medigap in 2018
54% had Plan F (MOST COSTLY, covers Deductibles and excess charges))

14

What do Benes PAY? 

for MediGAP Plans

Monthly premiums that depend on:
Health / age / location / plan

Estimated annual cost range from 8250 -> 8490 in our area

Plans A-N all VARY

most common is Plan F (54% of the 20% that get medigap)
MOST EXPENSIVE

15

What is the Medicare Part C Plan?

Was a way for people to get PRESCRIPTION COVERAGE before Med D came along​

Medicare Advantage Program  (MA)
MANAGED CARE PLANS
run by PRIVATE companies = HMO / PPO / etc

Give access to physicials + other providers that are often limited to those in network

Inclusions of extra benefits + lower cost-sharing requirements than traditional medicare:
RX Drugs / Dental / Physicals / Vison / Health+Wellness

16

Trend of enrollment for

Medicare Advantage plans = Part C

Slight dip in 2000s

Normall Increased over time

Most PART C enrolees are in HMO's

varies across states

17

What is the MEDICARE PART D plan?

Outpatient PRESCRIPTION drug benefit
estabilised as part of Medicare Modernization act of 2003 --> 2006

Delivered through Private plans that contract w/ medicare
coverage / premiums VARY by plan

Bene's enroll in either private or Medicare Advantage (C)

PREMIUM varies by plan and by yearly income

18

Prescription Drug Plans

PDPs

PART D

PRIVATE stand-alone plans that offer RX drug coverage ONLY
(add drug coverate to original medicare)

25% REDUCTION in # of plans since 2015

 

Average of the 10 most popular Part D stand-alone PDPs:

Premium = 20-84$

19

Medicare Advantage RX Drug Plans

MA-PDs

Drug coverage that is integrated with the health coverage provided by the private managed care plan

(HMOs + regional PPOs)

 

20

Standard Medicare Prescription Drug Benefit 2018

21

PART D Plan

Drug Coverage

 

Must wait until next open enrollment period to SWITCH part D plans

Oct 15 - Dec 7

LARGE VARIABILITY
amoungst each PDP in what drugs are covered
not every plan covers the same drugs

May NOT pay to enroll if a person spend

(average cost of the premium + deductible)
@ risk for UNEXPECTED need for meds

 

22

Need to SHIFT the spending

Need to PREVENT / KEEP OUT OF HOSPITAL

medicare advantage is better

23

24

Affordable Care Act

in MEDICARE

PART D benefit
FIllin in donut hair -> provide discount for brand name drugs in GAPS

Physician Reimbursement
10% bonus payment for PCP's

Patient Cost-Sharing
Elminates Cost sharing for services recommended by US preventative services tast force

ACOs

Readmision Reducation Program

25

What is MedicAID?

Aid the Not Paid

Social Security act of 1965 -> for limited income & assets

JOINT STATE & FEDERAL PROGRAM

Eligibility varies by the statewithin federal rules

26

WHO is covered by MedicAID?

All Adults <138% FPL (federal poverty line)

 

Before ACA, Medicaid only covered SPECIFIC categories of low income individuals + other groups:
Children + Pregnant Women
Parents of dependnt children + Individuals w/ disabilities + Age 65+

27

Medicaid Enrollment WAS declining now is back up

 

SENSITIVE TO GVMT SPENDING & ECONOMY HEALTH

28

Medicaid SPENDING is MOST with the DISABLED

 

Enrollment is highest with Children + Adults

29

ACA's Impact on

MedicAID's Expansion

LARGE Increase in MedicAID Enrollment

reductions in uninsured rates

Coverage gains in specific populations:
Young adults / HIV / Parents / mothers / Children / Rural area

Expension positively impacts acess to care

Improvements in self-reported health

30

How did the ACA help fill in the donut hole?

in PART D Benefit

Require manufactururers to provide

DISCOUNT (50%) for brand name drugs filled in coverage gap

 

Donut hole = gap/space where patients paid a large % of the drug price