Social Insurance/Comparative H.C Systems Flashcards
(33 cards)
What is Medicare?
A social insurance that consists of 2 main parts (Part A and B) along with Part C & D that provides coverage to beneficiaries who are 65 years or older.
Medicare Part A
Hospital insurance that covers only inpatient services and copayments. Automatically given to those 65 and older. Also covers skilled nursing facilities, home health care, and hospice.
Medicare Part B
- Available to all residents 65 and older.
- It is optional and must pay a premium to obtain it
- Covers outpatient services along labs and clinical services (basically not everything covered by Part A).
Medicare Part C
The Medicare Adv. Plan that is coordinated with PPOs, HMOs, and POSs and are chosen by the beneficiary to extend benefits. Only entitled to certain providers.
Medicare Part D
Prescription portion that provides access to drug insurances. A premium also needs to be paid in order to obtain it. It is entitled to individuals entitled to Part A & B who have low income.
How is Medicare Part A Financed?
Financed primarily through Mandatory Payroll Deduction (FICA) tax. Takes 1.45% from employee earnings and 2.90 % from self employed persons.
How is Medicare Part B & D financed?
Financed by SMI trust fund where premium payments are collected trust fund. Any extra funds is contributed from U.S Treasury.
Medicare Liabilities
For those with Medicare Part A and B, beneficiaries are liable for charges not covered by Medicare and for various cost-sharing features.
Medigap
A third party that assists with covering for liabilities that the beneficiary cannot pay. It is a private health insurance that covers for services that Medicare Part A and B cannot cover.
What is Medicaid?
- Also known as Title XIX of the Social Security Act
- A federal state matching program where certain criteria is met to provide coverage.
- Serves America’s poorest communities
- Largest funding program
- Cost sharing partnership between Federal Gov’t and State Medicaid Program.
How is Medicaid Financed?
It is financed by the federal and state governments. Funding is determined through shares of medical expenditures by each states Federal Medical Assistance Percentage Program (FMAP).
Federal Medical Assistance Percentage (FMAP)
A formula that compares the state’s average per capita income level with the national income average. For instance, with states with higher per-capita income levels are reimbursed smaller shares of their costs.
Medicaid Eligibility among Individuals and States…
For individuals, eligibility is determined by the state and federal funding to the states is determined if the states are providing Medicaid Coverage to certain individuals who receive federally assisted income as well as not receiving cash payments.
4 criteria for a state to meet eligibility for state funding:
- Have low income families with children
- Families with children under 6 or pregnant whose family income is below the 133 % federal poverty level.
- All children under age 19 with incomes at or below the FPL
- “Dual eligible” Medicare Beneficiaries.
Dual Eligible
Medicare Beneficiaries entitled to Medicare through Medigap. Establishes the relationship between Medicare and Medicaid.
Who is considered the “payor of the last resort” and why?
Medicaid is considered so because Medicare in a dual eligibility will try to cover the services first before Medicaid will.
Medicare and Medicaid have ____ interests in _____ costs, but _____ have an incentive to _______ for the management of care.
Medicare and Medicaid have similar interests in limiting costs, but neither have an incentive to take responsibility for management of quality of care.
When shifting costs, what do Medicare and Medicaid cover?
Medicare is the primary payer in a dual eligible that covers hospital, physician, and other acute medical care while Medicaid (based on states discretion) chooses to pay the often considerable Medicare copayments.
Conflicts arise in cost sharing between which two groups and why? (Hint: Not with Medicare)
Between Medicaid and the state because the state may have more restrictive policies on cost sharing where as the Medicaid program itself does not. Depending on the state, this can cause individuals to receive less access to treatment.
What did Medicare have conflicting incentives with around 1983?
Conflicts between Medicare and prospective system. With the usage of DRG’s, this caused patients to be discharged “sicker and quicker”. This led to post acute nursing homes to be covered by Medicare after discharge.
Possible Solutions to Conflicting Incentives?
- Coordinate the two programs
- Shift financial responsibility of “dual eligible” to federal government.
- PPACA creates “office of the duals”
For public insurance, what are two challenges that they face that prevent successful outreach?
- Lack of Knowledge
2. Stigma
Gruber (2002) identifies two things that are net impacts of social insurance implementation?
- Take up
2. Crowd out
Take up
Previously uninsured and did not have Medicaid before
