Medicare and Medicaid

For Medicare Part D requirement "Have Filled Multiple Covered Part D Drugs" sponsors cannot what?

"Sponsors *cannot require more than 8* Part D drugs as the minimum number of Pard D drugs as a beneficiary must have filled to be eligible for the MTM program"

What deductible must be meat to cover costs for Medicare Part A?

$1,288 Deductible

For Medicare Part B, Beneficiary Premiums range from __________ to __________ depending on several factors

$104.90 to $389.80

In 2017, Part B beneficiaries are subject to what deductible?

$183

Medicare Part D premiums averaged _____________ per month during 2016.

$41

What population is the growing share of Medicaid?

Seniors

For Medicare Part D requirement "Be likely to incur annual costs for covered Part D drugs that exceed a level specified by the Secretary" sponsors must what?

Sponsors must target beneficiaries who meet the other two criteria and who are likely to incur *annual costs* for Part D drugs of at least *$3,919*

Medicare started with what programs?

Started with Parts A & B benefit programs

Medicare Supplement Insurance Policies (Medigap Coverage) plans are provided by what?

These plans are provided by private insurance companies and supplied supplemental coverage for 20% of beneficiaries in traditional Medicare (Parts A & B) in 2011.

Who is exempt from the general enrollment of Medicare?

Those with comparable health insurance coverage are exempted

Is the Medicaid program run by the federal or state government?

Though funded jointly by the federal government and the states, each state operates its own Medicaid program within federal guidelines.

Why is the Quality Payment Program important for pharmacists?

Though pharmacists are not directly involved in the program, there may be potential tie-ins through primary care and specialized care models.

For Medicare Advantage, Medicare beneficiaries can enroll in what?

a private health plan such as a HMO or PPO while receiving all Medicare-covered benefits - Part A, Part B, and (typically) Part D

Those who choose the fee-for-service (Parts A & B) structure must enroll in what?

in a Part D prescription benefit plan every year during a 2 month period at the end of the year, or the Medicare Enrollment Period

The number of beneficiaries enrolling in Medicare Advantage has (increased or decreased)?

increased The number of beneficiaries enrolling in Medicare Advantage has grown from 6.9 million in 1999 to *17 million beneficiaries in 2015 - or 31% of all Medicare Beneficiaries*

Under Medicare Part B, Medicare reimburses at what?

ASP(Average Sales Price)+6%

What is Coverage Gap "Donut Hole"?

After Medicare pays out a certain dollar amount to the patient, the patient is responsible for a percentage of all drug costs until another dollar threshold is met

What is Catastrophic Coverage?

After leaving the coverage gap, patients are responsible for no more than 5% of drug

What is Initial Coverage?

After the deductible phase, patients are subject to normal copayments and coinsurance amounts

What group is involved in general enrollment of Medicare?

Age 65

When is general enrollment open to seniors?

All seniors must enroll in the Medicare program within 3 months before or after turning 65

How is Medicare Advantage covered?

is funded from the same sources as Medicare Parts A, B, and D

For Medicare Part A what does coinsurance cover?

long term stays in inpatient hospitals and SNF

The Medicare Part B excess charges are covered by which Medigap Plans?

F and G

What is Medicare?

Federal health insurance coverage created in 1965 for people ages 65 and older.

How is Medicare Part D funded?

General revenues, beneficiary premiums, & state payments

Although the federal guidelines are broad for Medicaid, many states have yet to what?

many states have yet to expand their Medicaid program as allowed under the Patient Protection and Affordable Care Act.

Medicare Advantage plans vary in benefit design, which means what?

means premiums, deductibles, copayments, coinsurance, formularies, and network differ widely depending on the "sponsoring" plan *Think Private Insurance...*

For general enrollment, beneficiaries can choose what?

medical coverage under Parts A & B, or the "traditional fee-for-service" structure or under the managed care structure of Part C.

With the Medicaid expansion, The US Supreme Court also held that the "individual mandate" to purchase insurance was to be deemed as a tax, and therefore what?

not mandatory

What does Medicare Part A involve?

Hospital benefits

What is Children's Health Insurance Program(CHIP)?

Provides health insurance for children up to age 19 and those not already insured (with additional requirements).

Medigap Plans K and L have what?

out-of-pocket limits of $4,660 and $2,330 respectively in 2012.

Many Dual Eligible Beneficiaries choose to receive what?

special coordinated care through a D-SNP, a special needs plan for duals.

The Patient Protection & Affordable Care Act originally mandated states to expand coverage of their Medicaid programs or else face a withholding of federal subsidies to states for the Medicaid program. However, in 2012, the US Supreme Court held that states do not what?

states do not have to expand Medicaid and all federal subsidies for Medicaid cannot be withheld from a state that chooses to not expand their Mcd program.

19 states have not expanded Medicaid to additional persons. This means what?

that Medicaid is generally limited to working parents with incomes up to 44% of the poverty line.

What did the The Medicare Access & CHIP Reauthorization Act (MACRA) create?

the Quality Payment Program to bring quality and value to Medicare payments.

What did to the creation of the Alternative Payment Models do?

the federal government is changing the way we pay for care. Instead of being about volume, it will be more focused on value, quality of care, and outcomes.

Special enrollment protections exist for the who?

the most financially and clinically vulnerable patients as well as for those in low performing plans

In states that do not expand Medicaid under the ACA, there will be what?

there will be large gaps in coverage available for adults

Custodial Long Term Care, Dental, Vision, Hearing and may be apart of what?

these may be a part of a Medicare Part C plan's benefit packages as they are allowed to cover more than what Parts A & B allow.

If beneficiaries choose the managed care structure, they must what?

they must also enroll in a Part C Medicare Advantage plan every year during the Medicare Enrollment Period

SNPs currently are required to be reauthorized by who?

though current legislation may make it permanent.

31 states & DC have expanded their Medicaid program to who?

to parents and childless adults with incomes up to 138% of the poverty line.

The Part D Enhanced Medication Therapy Management (MTM) model will test what?

will test whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will engender enhancements in the MTM program, leading to improved therapeutic outcomes, while reducing net Medicare expenditures."

In 2017, Part B beneficiaries are subject to what coinsurance?

20%

What happened to Medicare in 1997?

A new type of coordinated benefit created in 1997. Created the Part C benefit.

What does Medicare Part C involve?

Comprehensive managed care benefits.

What is Deductible Phase?

Coverage may not begin until a deductible has been met.

Compare and contrast CHIP and Medicaire.

Like Medicaid, this is a federal/state partnership where states get to set their own guidelines within Federal restrictions. However, unlike Medicaid, CHIP is not an entitlement program

What is Medicaid?

Medicaid is a public insurance programs that provides health coverage to low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities.

What is medicare Part C also known as?

Medicare Advantage

For Medicare Part D requirement "Have Multiple Chronic Diseases" sponsors what?

1.) "Sponsors *cannot require more than 3* chronic conditions as the minimum number of multiple chronic diseases" 2.) "Sponsors must target *at least five* of the nine core chronic conditions"

Dual eligible beneficiaries make up ______ of all Medicaid beneficiaries and _______ of all Medicare beneficiaries.

1.) 15% 2.) 20%

What are the three main characteristics of the Medicare population?

1.) 3+ chronic conditions 2.) Income below $24,150 3.) Under age 65 with permanent disabilities

Dual eligible beneficiaries take up _______ of all Medicaid spending and ______ of all Medicare spending

1.) 39% 2.) 31%

Who does Medicare cover?

1.) All seniors 65 years or older who paid or whose spouse paid Social Security taxes for at least 10 years. 2.) Persons under 65 years of age with permanent disabilities

In 2017, Part B beneficiaries are subject to 20% coinsurance except for what?

1.) An annual "wellness visits" and 2.) Some preventive services

Since Medicaid is an "entitlement" program what?

1.) Anyone who meets eligibility rules has a right to coverage and 2.) States have guaranteed federal financial support for part of their Medicaid costs

To receive federal funding, states must cover what certain "mandatory" populations for Medicaid?

1.) Children through age 18 in families with income below 138% of the federal poverty line (FPL) ($25,975 for a family of three in 2013) 2.) Pregnant women with income below 138% of FPL 3.) Parents whose income is within the state's eligibility limit for cash assistance that was in place prior to welfare reform 4.) Most seniors and persons with disabilities who receive cash assistance through the Supplemental Security Income (SSI) program

What did the ACA change for Medicare?

1.) Closes Part D coverage gap by 2020 2.) Covers preventative services 3.) No copayments and deductibles 4.) Annual Wellness Visits 5.) Higher premiums for higher incomes 6.) Medicare Advantage adjustments 7.) Reduced payments for Hospital Readmissions 8.) Extends Trust Fund solvency 9.) Payment Reforms

What is Typically Not Paid for By Medicare Parts A & B?

1.) Custodial Long Term Care 2.) Dental 3.) Vision 4.) Hearing

What are the Three Phases of a Part D Beneficiary's Coverage Calendar Year?

1.) Deductible Phase 2.) Initial Coverage 3.) Catastrophic Coverage

For State Administration of Medicaid, within broad Federal guidelines, each state must what?

1.) Develops its own programs 2.) Develops and operates it own State Plan for Medicaid 3.) Establishes its own eligibility standards 4.) Determines the type, amount, duration & scope of services 5.) Sets the rate of payment for services 6.) Administers it own program 7.) May change eligibility, services, and reimbursements

What Outpatient Drugs Covered By Medicare Part B?

1.) Drugs used with an item of DME, including COPD medications given by a nebulizer 2.) Erythropoiesis-stimulating agents for patients with ESRD 3.) Clotting factors given by self-injection by hemophilia patients 4.) Most injectable drugs given by a licensed medical provider 5.) Parenteral (intravenous) and enteral (feeding tubve) nutrition 6.) Immune Globulin (IVIG) upon diagnosis of primary immune deficiency 7.) Three immunizations administered in doctor's office: Influenza, Pneumococcal, Hepatitis B (with increased risk of exposure) 8.) Immunosuppressive drugs upon organ or tissue transplantation for which Medicare made payments

When applying for Medicare, Special criteria apply for those with what?

1.) End Stage Renal Disease (ESRD) 2.) Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)

Under 42 CFR §423.153(d), a Part D sponsor must establish an MTM program that what?

1.) Ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use 2.) Reduces the risk of adverse events, 3.) Is developed in cooperation with licensed and practicing pharmacists and physicians, 4.) May be furnished by pharmacists or other qualified providers

Part B is funded by what?

1.) General Revenues 2.) Premiums paid by Medicare Beneficiaries

As per federal regulations, a beneficiary must meet all of what criteria in order to qualify for MTM services?

1.) Have multiple chronic diseases 2.) Have filled multiple covered Part D drugs 3.) Be likely to incur annual costs for covered Part D drugs that exceed a level specified by the Secretary ($3,919 in 2017)

What are the nine core chronic conditions?

1.) Hypertension 2.) Heart Failure 3.) Diabetes 4.) Dyslipidemia 5.) Respiratory Diseases 6.) Alzheimer's Disease 7.) Bone Disease/Arthritis 8.) Mental Health Disorders 9.) End Stage Renal Disease (ESRD)

Mandatory Medicaid State Plan benefits include what?

1.) Inpatient & outpatient hospital services 2.) Physician services 3.) Rural and Federally-qualified health centers 4.) Laboratory & X-ray 5.) Nursing facility services for adults 6.) Early periodic screening & diagnostic testing 7.) Family planning 8.) Home health 9.) Nurse-midwife services 10.) Nurse practitioner services

Medicare Part A covers what?

1.) Inpatient hospital stays 2.) Skilled nursing facilities (SNF) 3.) Home health visits 4.) Hospice care

Medicare also provides coordinated care coverage for patients with what special needs?

1.) Institutional SNP (I-SNP) 2.) Dual Eligible SNP (D-SNP) 3.) Chronic Condition SNP (C-SNP)

What are the Required MTM Services?

1.) Must target beneficiaries AND prescribers 2.) Offer a Comprehensive Medication Review (CMR) by a pharmacist or other qualified provider at least annually to all targeted beneficiaries enrolled in the MTM program (including LTC beneficiaries) 3.) Interactive, person-to-person or telehealth consultations 4.) Quarterly targeted medication reviews (TMRs) with follow-up interventions when necessary

Part A is funded by what?

1.) Payroll tax of 2.9% paid by both employer and employee (higher rate for higher income employees) 2.) These tax dollars are placed in the Hospital Insurance Trust Fund, which is projected to be solvent through 2030

Medicare Part B covers what?

1.) Physician visits 2.) Outpatient services 3.) Preventive services 4.) Home health visits

What are the optional populations that states may also receive federal Medicaid funds?

1.) Pregnant women 2.) Children 3.) Parents with income above "mandatory" coverage income limits 4.) Seniors and persons with disabilities with income below the poverty line 5.) "Medically needy" people with incomes above poverty line 6.) Near-poor non-disabled adults without children (under new reform)

Optional Medicaid benefits include what?

1.) Prescription Drugs 2.) Physical, occupational, speech, audiology therapy 3.) Prosthetic devices, optometry services, glasses 4.) Some mental health services Some substance abuse services 5.) Special services in waivers and demonstrations 6.) Transportation services 7.) Hospice care 8.) Home and community based care for certain persons with chronic impairments

What are some future changes to Medicare?

1.) The Medicare Access & CHIP Reauthorization Act (MACRA) 2.) creation of Alternative Payment Models

How is Medicaid Funded?

1.) Together, states and the federal government spent about $476 billion on Medicaid services in fiscal year 2014. 2.) The federal government matches at least 100% of what a state spends on Medicaid. This amount is larger in states with poorer populations. This ratio is known as the FMAP. 3.) The federal government pays an average of between 57 - 60% of Medicaid program costs and as high as 75% in some states. 4.) States have large discretion over who is eligible and what services are covered. Therefore, states largely determine how much federal subsidies they will/are willing to receive.

How is Medicare Different from Medicaid?

1.) While Medicare is a national program that is consistent across the country, Medicaid consists of statewide programs that vary among states. 2.) While Medicare is administered by the Federal government, Medicaid is administered by state governments within Federal rules (Federal/state partnership). 3.) While Medicare eligibility is based on age, disability, or End-Stage Renal Disease (ESRD), Medicaid eligibility is based on income and resources. 4.) While Medicare is the nation's primary payer of inpatient hospital services to the elderly and people with ESRD, Medicaid is the nation's primary public payer of acute health, mental health, and long-term care services.

When was Medicaid created?

1965

The Medicare Part A deductible is covered by which Medigap Plans?

B, C, D, F, G, K, M (at 50%), L (at 75%), and N (at 100%)

Why do states have a great deal of flexibility in designing and administering their Medicaid programs?

Because the federal guidelines are broad

What is Dual Eligible SNP (D-SNP)?

Beneficiary has both Medicare and Medicaid coverage

What is Chronic Condition SNP (C-SNP)?

Beneficiary has one or more of the listed severe or disabling chronic conditions

What is Institutional SNP (I-SNP)?

Beneficiary lives in an institution (like a nursing home) or requires nursing care at home.

Coverage of low income population, Access to care, long term care safety net, the payer of last resort do what?

Briefly touch Medicare Beneficiaries

The Medicare Part B deductible is covered by which Medigap Plans?

C and F

The Skilled Nursing Facility care coinsurance is covered by which Medigap Plans?

C, D, F, G, K (at 50%), L (at 75%), and M, N (at 100%)

Foreign travel emergency costs up to the plan's limits are covered by which Medigap Plans?

C, D, F, G, M and N

What happened to Medicare in 1972?

Expanded in 1972 to cover people under age 65 with permanent disability. Still Parts A & B

What does MTMP stand for?

Medication Therapy Management Program

What does Medicare Part D cover?

Outpatient prescription drugs through private plans (or sponsors) that contract with Medicare as part of both stand-alone prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PD)

What does Medicare Part B involve?

Physician Benefits

Medigap Plan F has a what?

Plan F has a high-deductible option

What does Medicare Part D involve?

Prescription Drug Benefits

What happened to Medicare in 2003?

Prescription drug coverage added in 2003 through Medicare Modernization Act. Created the Part D benefit.

Who is covered under CHIP?

Uninsured children and pregnant women who: 1.) Family income too high for Medicaid 2.) Uninsured children with higher family income 3.) Uninsured low income pregnant women 4.) Children born to women receiving pregnancy related assistance (automatic enrollment into Medicaid or CHIP)

What is enrollment in Medicare Part C and D open?

Yearly Enrollment (starts @ Oct, goes through Dec)

By not expanding Medicaid, states are choosing to not spend additional dollars but are what?

are also forgoing additional federal dollars.

What are Dual Eligible Beneficiaries eligible for what?

are eligible for both Medicare and Medicaid. They may receive coverage through Medicaid, Medicare, or both.

Because the federal guidelines are broad, states have a great deal of flexibility in designing and administering their programs. Therefore, Medicaid eligibility and benefits can what?

can and often do vary widely from state to state

Those in a Special Needs Plan (SNP), full or partial LIS (Low Income Subsidiary) or "Extra Help" beneficiaries, those enrolled in an under-performing plan, or other special circumstance can what?

can switch plans at any time during the year, or the Special Enrollment Period.

When does special enrollment occur?

can take place throughout the year

IN 2009 only 5 states covered ____________ under Medicaid

childless adults

Each Medigap Plan covers what?

covers different benefits

Medigap plans partially cover Medicare Parts A & B cost-sharing requirements, including what?

deductibles, copayments, and coinsurance.

When applying for Medicare, individuals with ESRD or ALS do *not* have to what?

do not have to wait the required 2 years after receiving SSDI (Social Security Disability Insurance) payments.

When applying for Medicare, individuals with other permanent disabilities are subject to what?

have to wait the required 2 years after receiving SSDI (Social Security Disability Insurance) payments