Healthcare Finance

Question 1

Most Common Types of Healthcare Coverage in US

Answer 1

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

Question 2

Percentage of Adults Uninsured

Answer 2

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

Question 3

Characteristics of people uninsured

Answer 3

Young
Latina/Hispanic
Poor
Sicker
Living in South

Question 4

Breakdown of Federal Budget in 2022

Answer 4

Social Security
- 4.8% GDP
- 1.2 trillion

Medicare
- 3.0% GDP
- 747 billion

Medicaid
- 2.4% GDP
- 592 billion

Question 5

Breakdown of State Budget in 2022

Answer 5

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

Question 6

Why do people need health insurance?

Answer 6

Healthcare is expensive and uncertain

Question 7

Health Insurance in 1900s

Answer 7

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

Question 8

Why were costs in the past low compared to today?

Answer 8

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

Question 9

History of Health Insurance Timeline

Answer 9

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

Question 10

Goals of ACA

Answer 10

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

Question 11

30 Day Readmission Penalties

Answer 11

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

Question 12

Lyndon B Johnson

Answer 12

• 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

Question 13

Medicare

Answer 13

started: July 1, 1966

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

NO DENTAL OR EYE

NO DRUG BENEFIT FOR OUTPATIENTS

Question 14

Medicare Enrollment & Spending in Future

Answer 14

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

2021: 689 billion
2031: 1.6 trillion

Question 15

Fasting growing part of Medicare

Answer 15

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

Question 16

Parts of Medicare

Answer 16

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

Question 17

Enrolling in Medicare

Answer 17

• 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

Question 18

What is not covered by Part B

Answer 18

LTC
Dental
Cosmetic
Eye exam
Routine Foot care
Hearing Aids
Acupuncture

Question 19

Medigap

Answer 19

• 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

Question 20

Advantage Plan Features

Answer 20

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

Question 21

Medicare Star Rating System

Answer 21

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

Question 22

Medicare Part D

Answer 22

• 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

Question 23

Medicare Donut Hole

Answer 23

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

Question 24

Medicaid

Answer 24

• Started: January 1, 1966

health insurance for the poor and medically indigent

NOT REQUIRED (AZ added in 1982)

Question 25

Federal-State Partnership Program in Medicaid

Answer 25

managed by state govt standards by federal govt matching funds based on state per capita income

Question 26

Impact of Medicaid on US Social Welfare Program

Answer 26

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

Question 27

ACA and Medicaid

Answer 27

- 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

Question 28

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

Answer 28

> 50%

Question 29

How does Medicaid compare to Private Insurance?

Answer 29

Medicaid is comparable to private insurance for access to care for adults and children uninsured fare far less

Question 30

Who spends the most per enrollee in Medicaid

Answer 30

Individuals with disabilities and elderly

Question 31

Medicaid Drug Spending and Rebates

Answer 31

more money is coming back as rebates than net spending

Question 32

What populations make up the most enrollment in Medicaid

Answer 32

1. Children 2. Pregnant women

Question 33

What service does IN Medicaid spend the most on?

Answer 33

Managed Care

Question 34

What percent of IN Medicaid enrollees are people of color?

Answer 34

39%

Question 35

What percent of IN Medicaid enrollees are working?

Answer 35

65%

Question 36

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

Answer 36

Southern

Question 37

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

Answer 37

Texas Florida Georgia North Carolina

Question 38

Who qualifies for Medicaid?

Answer 38

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

Question 39

How long are pregnant mothers covered for after pregnancy ends?

Answer 39

12 months

Question 40

Work Status of Women on Medicaid

Answer 40

most women covered by Medicaid work outside the home for pay

Question 41

Medicaid Options

Answer 41

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

Question 42

Mandatory Services by Medicaid

Answer 42

LTC Hospital Physician Home Health Prenatal care Family Planning

Question 43

National Enrollment of Medicaid

Answer 43

60% of nursing home residents 40% of childbirths

Question 44

National Eligibility of Medicaid

Answer 44

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

Question 45

Dental Coverage of Medicaid

Answer 45

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

Question 46

Medicaid Reimbursement

Answer 46

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

Question 47

American Rescue Plan

Answer 47

- 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