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PHRM 849 > Healthcare Finance > Flashcards

Healthcare Finance Flashcards

1
Q

Most Common Types of Healthcare Coverage in US

A
  • Employer Only Insurance: 48.7%
  • Medicaid Only: 15.2%
  • Uninsured: 8%
  • Medicare + Private: 7.7%
  • Medicare Only: 6.8%
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2
Q

Percentage of Adults Uninsured

A

More than 2/5 of working adults are inadequately insured
- 23% underinsured
- 11% coverage gap
- 9% uninsured

Up to 1/4 of working adults have not filled a prescription in the past year for their chronic health condition because of the cost
- highest is asthma

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3
Q

Characteristics of people uninsured

A

Young
Latina/Hispanic
Poor
Sicker
Living in South

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4
Q

Breakdown of Federal Budget in 2022

A

Social Security
- 4.8% GDP
- 1.2 trillion

Medicare
- 3.0% GDP
- 747 billion

Medicaid
- 2.4% GDP
- 592 billion

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5
Q

Breakdown of State Budget in 2022

A
  1. Education
  2. Health & Human Services
  3. Transportation
  4. Public Safety (state police officers, prisons)
  5. Government
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6
Q

Why do people need health insurance?

A

Healthcare is expensive and uncertain

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7
Q

Health Insurance in 1900s

A
  • before insurance, patients were expected to pay healthcare costs out of pocket
  • few hospitals, cash, MDs came to patient’s home
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8
Q

Why were costs in the past low compared to today?

A

there was not as much treatment options that were expensive to use and pay for

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9
Q

History of Health Insurance Timeline

A

1920s: hospitals offered pre-paid plan

1929: first employer-sponsored plan by teachers in Dallas

1935: Social Security Act — no health coverage

WWII: EMPLOYER SPONSORED PLANS OFFERED AS BENEFIT EXPANDED AS A RESULT OF WAGE CONTROLS

1946: Hill Burton Act — hospital construction

1954: tax deduction for employers in Revenue Act

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10
Q

Goals of ACA

A
  • improve accessibility to coverage
  • improve efficiency of care
  • decrease number of uninsured
  • decrease cost of care
  • IMPROVE QUALITY OF CARE
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11
Q

30 Day Readmission Penalties

A
  • data shows that 75% of readmissions are preventable saving up to 12 billion/year
  • ACA penalizes hospitals for readmission rates
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12
Q

Lyndon B Johnson

A
  • made passage of Medicare his top priority
  • president truman and wife were first two medicare cards
  • Medicare/Medicaid was enacted as Title 18/19 of Social Security Act in 1965
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13
Q

Medicare

A

started: July 1, 1966

health insurance for:
- elderly (> 65 yo)
- disabled
- ESKD or ALS

NO DENTAL OR EYE

NO DRUG BENEFIT FOR OUTPATIENTS

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14
Q

Medicare Enrollment & Spending in Future

A

aging population will contribute to higher Medicare enrollment
- 1966: 19 million
- 2020: 63 million
- 2060: 93 million

2021: 689 billion
2031: 1.6 trillion

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15
Q

Fasting growing part of Medicare

A

Physician service and Part B services account for the largest share of Medicare Benefit spending

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16
Q

Parts of Medicare

A

Part A
- covers hospital costs
- no premium costs
- SNF care: max 100 days

Part B
- covers physician costs & medical supplies & drugs administered in MD office — not required
- premium costs deduced from SS

Part C
- A, B, D
- managed care

Part D
- covers drug benefit
- premium costs deducted from SS

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17
Q

Enrolling in Medicare

A
  • enrollment can begin about 3 months before 65th birthday (do not have to be required)
  • YOU DO NOT HAVE TO ENROLL AS LONG AS YOU HAVE COMPARABLE INSURANCE PLAN
  • begins when you start receiving Social Security benefits

Part A is normally free —> you do not have to accept Part B unless you do not have adequate insurance leading to a penalty

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18
Q

What is not covered by Part B

A

LTC
Dental
Cosmetic
Eye exam
Routine Foot care
Hearing Aids
Acupuncture

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19
Q

Medigap

A
  • not administered by CMS but standardized by federal law
  • picks up deductibles for Part A and deductibles and costs for Part B

PURCHASED THROUGH PRIVATE COMPANIES

20
Q

Advantage Plan Features

A
  • administered by private companies
  • premiums CAN BE lower than regular Medicare
  • offer extra benefits like vision and dental
21
Q

Medicare Star Rating System

A

used by CMS to measure how well Medicare Advantage and Part D plans perform
- reviewed annually
- 1 to 5

22
Q

Medicare Part D

A
  • largest change in insurance processing in retail history
  • not a single entity —> beneficiaries need to voluntarily enroll (average cost is 41$)
  • RUN BY PRIVATE INSURANCE COMPANIES
  • formularies for each plan are different
23
Q

Medicare Donut Hole

A
  1. Start paying as your deductible resets in January 1
  2. you only pay copay’s for covered drugs
  3. coverage gap: you pay a certain percentage based on drug type
  4. your plan starts paying 100% until the end of year
24
Q

Medicaid

A
  • Started: January 1, 1966

health insurance for the poor and medically indigent

NOT REQUIRED (AZ added in 1982)

25
Q

Federal-State Partnership Program in Medicaid

A

managed by state govt

standards by federal govt

matching funds based on state per capita income

26
Q

Impact of Medicaid on US Social Welfare Program

A

Medicaid pays for:
- 1 in 6 dollars in HC system
- 1 in 2 dollars on long term services/supports

27
Q

ACA and Medicaid

A
  • ACA expands Medicaid eligibility for states to opt in
  • allows people with income up to 138% of federal poverty level to qualify (17775 single or 36570 for 4)
  • Medicaid and HC has become a political football
28
Q

What percent of nation’s uninsured live in states that have opted out of Medicaid expansion?

A

> 50%

29
Q

How does Medicaid compare to Private Insurance?

A

Medicaid is comparable to private insurance for access to care for adults and children

uninsured fare far less

30
Q

Who spends the most per enrollee in Medicaid

A

Individuals with disabilities and elderly

31
Q

Medicaid Drug Spending and Rebates

A

more money is coming back as rebates than net spending

32
Q

What populations make up the most enrollment in Medicaid

A
  1. Children
  2. Pregnant women
33
Q

What service does IN Medicaid spend the most on?

A

Managed Care

34
Q

What percent of IN Medicaid enrollees are people of color?

A

39%

35
Q

What percent of IN Medicaid enrollees are working?

A

65%

36
Q

What region of the US has the majority of the states not expanded Medicaid?

A

Southern

37
Q

70% of Uninsured Adults would become eligibile for Medicaid if what 4 states expanded?

A

Texas
Florida
Georgia
North Carolina

38
Q

Who qualifies for Medicaid?

A
  • low income families < 138% of FPL
  • infants born to Medicaid eligible pregnant woman
  • children < 6 yo & pregnant women < 158% of FPL
  • certain Medicare beneficiaries
39
Q

How long are pregnant mothers covered for after pregnancy ends?

A

12 months

40
Q

Work Status of Women on Medicaid

A

most women covered by Medicaid work outside the home for pay

41
Q

Medicaid Options

A

Hoosier Healthwise (MCO) –> 786,977
- children and pregnant women

Health Indiana Plan (HIP) –> 778,383
- low income adults < 138% of FPL

Traditional Medicaid (Fee for Service) –> 351,447
- > 65 eligible for Medicare
- LTC
- waiver services

Hoosier Care Connect (MCO) –> 95.582
- > 65 not eligibile for Medicare
- blind/disabled

42
Q

Mandatory Services by Medicaid

A

LTC
Hospital
Physician
Home Health
Prenatal care
Family Planning

43
Q

National Enrollment of Medicaid

A

60% of nursing home residents
40% of childbirths

44
Q

National Eligibility of Medicaid

A

1/3 of all children are insured by Medicaid
60% of low income children insured by Medicaid

45
Q

Dental Coverage of Medicaid

A

children are eligible for dental coverage; however, DENTIST DO NOT PARTICIPATE

46
Q

Medicaid Reimbursement

A

historically reimbursed much less
- 68% normally
- 100% in 1/24

47
Q

American Rescue Plan

A
  • require federal government to negotiate prices for drugs covered by Medicare Part B/D
  • require drug companies to pay rebates to Medicare
  • cap out-of-pocket spending for Medicare Part D

PHRM 849 (26 decks)

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