Medicare and Medicaid

What is average Medicare spending and what is it spent on?

$5,368 Nearly half (49%) of beneficiaries' average total spending was for premiums for Medicare and other types of supplemental insurance, and 51 percent was for medical and long-term care services

How do MCO's work?

States pay the MCOs a monthly premium for each enrolled Medicaid beneficiary for their care; over half of all beneficiaries get their care through these plans

What is the Medicaid "coverage gap"?

The ACA provided Medicaid eligibility for low-income adults, but it did not provide financial assistance to purchase Marketplace coverage for those below 100% FPL As a result, in the states not adopting the Medicaid expansion, almost 4 million uninsured poor adults fall into a "coverage gap"

What are the Medicare eligibility requirements?

(1) Most people ages 65 and over are entitled to Medicare Part A if they or their spouse are eligible for Social Security payments and have paid payroll taxes for 10 or more years (2) People under age 65 who receive Social Security Disability Insurance (SSDI) payments generally become eligible for Medicare after a two-year waiting period (3) Those diagnosed with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS) become eligible for Medicare with no waiting period

What were the key ACA reforms?

- Establishing eligibility for nonelderly adults - Putting in place a uniform, national minimum income eligibility threshold of 138% FPL for nearly all individuals under age 65 *The effect of these changes was to establish Medicaid as the coverage pathway for low-income people in the ACA's broader system for covering the uninsured *To date, 29 states (including DC) have adopted the expansion

What are some important challenges and gaps in Medicaid?

- Physicians lower participation than in Medicare or private insurance - Low psychiatrist participation - Dental access

What is the difference in median Medicaid income limit for parents in expansion states vs nonexpansion states?

Expansion states provide Medicaid for adults up to 138% FPL median Medicaid income limit for parents in the nonexpansion states is just 46% FPL (an childless adults not eligible)

What *groups* are exempt from Medicaid cost-sharing?

mandatory eligible children, pregnant women, most children and adults with disabilities, people residing in institutions, and people receiving hospice care

What is Medicare Part C?

Refers to the *Medicare Advantage* program through which *beneficiaries can enroll in a private health plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), and receive all Medicare-covered Part A and Part B benefits and typically Part D benefits* Enrollment in Medicare Advantage plans has grown over time, with nearly 17 million beneficiaries enrolled in Medicare Advantage plans in 2015 (31% of all Medicare beneficiaries)

How is Medicaid financed?

2/3 acute care; 1/4 long-term care States and federal govt share the cost; the federal govt at least matches state contributions dollar-for-dollar (actual federal match rate called FMAP depends on average state income)

Pre-ACA, who was covered by Medicaid?

Certain low income individuals: children, pregnant women, parents of dependent children, individuals with diasabilities, and 65+ (NOT low income, childless adults)

What is Medicare Part A?

Covers *inpatient hospital stays, skilled nursing facility stays, some home health visits, and hospice care* - Part A benefits are subject to a deductible ($1,288 per benefit period in 2016) - Beneficiaries are subject to coinsurance amounts for extended inpatient stays in a hospital or skilled nursing facility

What are the problems associated with cost and coverage for Medicare?

- Relatively high deductibles and cost-sharing requirements - No limit on beneficiaries' out-of-pocket spending for services covered under Parts A and B - Medicare does not pay for some services that are important for older people and people with disabilities, including long-term services and supports, dental services, eyeglasses, and hearing aids - Medicare Part D has a coverage gap (also called the "doughnut hole") that will gradually close by 2020, when beneficiaries will pay 25 percent of the cost of their drugs in the gap

What were some items introduced in the ACA?

- States had option to expand medicaid to include those <133% FPL -Required states to simplify and modernize their enrollment processes - To create a coordinated eligibility and enrollment system for Medicaid, the Children's Health Insurance Program (CHIP), and the Marketplace, to facilitate enrollment and promote continuity of coverage

How many children do Medicaid and CHIP cover?

1 in 3 children in the US

How common is it to be "dual eligible" (for both Medicare and Medicaid)?

14% of all beneficiaries *Medicaid* (1) assists with their Medicare premiums/cost sharing and (2) provides long-term services (which Medicare does not)

What services are covered by Medicaid?

Both acute care services and a broad array of long-term services and supports that Medicare and most private insurance plans do not cover or tightly limit

What is Medicare Part D?

Covers *outpatient prescription drugs through private plans that contract with Medicare, including both stand-alone prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PD plans)* Enrollment in Part D plans is *voluntary* The benefit helps pay for enrollees' drug costs after a deductible is met (where applicable), and offers catastrophic coverage for very high drug costs. Enrollees pay monthly premiums and cost sharing for prescriptions, with costs varying by plan, and 5% of total drug costs after reaching the catastrophic threshold. Additional financial assistance is available for beneficiaries with low incomes and modest assets In 2015, 39 million people on Medicare were enrolled in a PDP or MA-PD plan.

What is Medicare Part B?

Covers *physician visits, outpatient services, preventive services, and some home health visits* - Part B benefits are subject to a deductible ($166 in 2016), and most Part B benefits are subject to coinsurance of 20 percent - No coinsurance or deductible is charged for an annual "wellness visit" or for preventive services that are rated 'A' or 'B' by the USPSTF

What *services* are exempt from Medicaid cost-sharing?

Emergency services, preventative services for children, pregnancy-related services, and family planning services

Where do supplemental coverage policies for Medicare usually come from?

Employer-sponsored retiree health plans (40%) Medigap policies, also called Medicare Supplement Insurance (20%) Medicaid for low-income (20%) None (20%)

Who gets federal help paying for healthcare insurance?

People who fall between 100-400% federal poverty line

What are the mandatory vs optional covered services for Medicaid?

Prescription drugs are technically optional but all states choose to cover them

What is an ACO?

allows groups of providers to accept responsibility for the overall care of Medicare beneficiaries and share in financial savings if spending and care quality targets are met