Phar738: Exam 1 compilation
How do you measure quality
HEDIS - healthcare effectiveness data and information set CAHPS - consumer assessment of healthcare providers and systems HOS - health outcomes survey
How to pay medical cost not covered by Medicare?
-private insurance for medical costs -supplement insurance (medical policies) don't provide prescription drug coverage unless purchase stand alone part d drug plan -military and VA health benefits (tricare/champva) -Medicaid - state administered federal subsidies. For low income individuals and certain disabilities
Hybrid: non assignment
-providers who don't accept assignment, but accept Medicare pt and bill Medicare (can charge patient more than Medicare approved amount and limited to 15% excess charges for soft services)
VA community care criteria
-service not already available at VA medical facility -veteran lives in US state/territory without full service VA medical history -qualifies under grandfather provision related to disability eligibility fro veteran choice program -if VA is unable to provide care within certain designated access standards -care is in veteran's best medical interest -VA does not meet certain quality standards -must be enrolled in VA healthcare -VA staff members make all eligibility decisions
How am I going to pay for prescription drugs
-stand-alone prescription drug plans -Medicare advantage plans that bundle prescription drug coverage with extra medical benefits
Travel coverage
-travel within US. Usual benefits if medicare provider (deductible for hospital; 20% co-pay outpt) -medigap: plan g = part b deductible if not already paid and other plan vary -advantage plan: co-pay 65-120 for emergency room and possibly urgent care -international travel -recommend travel insurance (Original medicare no coverage, medigap gives 80% reimbursement, and advantage is emergency room reimbursement but urgent care varies)
HMO vs PPO choosing them?
-want flexibility to see specialist without provider? (PPO) -want primary provider ? (HMO) -absolute lowest cost? (HMO) -get extra benefits (HMO) -go out of network (PPO) -Highest cost is a Medigap plan hmo < PPO < medigap
What are part b preventive services (free)
-wellness visits -abdominal aneurysm/cardiovascular/colorectal/diabetes/prostate cancer/mammogram screening -glaucoma tests -pap/pelvic/clinical breast exams -shots shots shots!! (Flu, pneumococcal, hepatitis) -smoking cessation
Veterans are assigned
1 of 8 priority groups which designate how son veterans sign up for health benefits and their cost Factors include military service history, disability, income medical eligibility, other benefits
medicare part d penalties
1% of the national base beneficiary premium for a part d plan for each full month an individual did not have part d or creditable coverage
Part D waiting to enroll penalty
1% premium increase for every full month delayed beginning 3 months after turning 65 or 6 months after leaving employer plan (based on avg premium 33.19/month, penalty paid as long as having medicare drug coverage) Exception is "creditable" coverage where drug coverage is as good as medicare drug coverage. Includes most employer plans >20 employees. VA drug coverage is creditable
The Oregon Health Plan is an example of... (SLO 1)
1) A Section 1115 Medicaid Waiver 2) A Medicaid demonstration project 3) Oregon's Medicaid program
What information is currently found on a beneficiary's Medicare Card? (Note: This question may have more than one answer) (SLO 1)
1) First and last name 2) Month and year the beneficiary started Part A and/or Part B
What is true about drug coverage under Medicare? (SLO 1)
1) The medications covered often varies across prescription drug plans. 2) Prescription drug plans can have a deductible that is lower than the standard deductible. 3) All stand-alone prescription drug plans charge a monthly premium.
What is true about drug coverage under Medicare? (SLO 1)
1) The term "coverage gap" or "donut hole" refers to time period where patients have historically paid higher costs for their prescriptions as compared to the initial benefit period. 2) Patient administered (i.e., self-administered) injectable drugs at home (e.g., insulin) are covered under Part D, but injectable drugs administered in a medical office or infusion center are covered under Part B. 3) Delaying enrollment in Part D can lead to a penalty equaling 1% per month of the national average for Part D premiums for each month delay.
What does contribute to a patient's out-of-pocket maximum? (SLO 1)
1)Deductible 2)Copay expenses 3)Coinsurance expenses
What differentiates the Children's Health Insurance Program (CHIP) from standard Medicaid? (SLO 1)
1)Financed through block grants 2)Higher income requirements (i.e., higher % FPL than standard Medicaid) 3)Higher federal matching formula
What are the federally-mandated eligibility categories for Medicaid? (SLO 1)
1)Pregnant women 2)Children 3)Old age / disabled 4)Adults with dependent children
IEP or initial enrollment period
1. 3 months before 65 2. Month of 65 3. 3 months after 65
Eligibility for medicare 3 pt
1. Been a US citizen for 5 continuous years 2. 65+ up don't need to be retired. Automatically enrolled if receiving SS benefits, otherwise you must apply via SS 3. Under 65 and receive SS disability benefits (no waiting period for those with end stage renal disease, ALS, or early onset Alzheimer's)
What are the similarities between Medicare Advantage plans and Oregon's coordinated care organizations? (SLO 1 & 2)
1. Both use a capitated plus bonus payment model to determine total reimbursement to the insurer 2. Both use county of residence to determine an individual's plan option(s). 3. Both are managed care approaches to delivering healthcare.
By law veterans are required copays for main 3 reasons
1. Care not related to service connected ailment 2. Income exceed threshold 3. Income info not available
Transition of care codes billing opportunity requirements
1. Communication with pt within 2 business days of hospital discharge 2. Face to face with provider with 7 days (complex complex) or 14 days (mod complexity)
Reimbursement methods
1. FFS 2. Defined criteria: per diagnosis - or DRG bundle payment reimbursement, per patient - capitation or certain amount of money per member per month, per year - salary (physician) and global budget (hospital)
Quadruple aim?
1. Improve population health 2. Reduce cost 3. Enhance pt experience 4. Improve care team wellbeing
Transition of care 3 outcomes
1. Leveraging interdisciplinary care team to reduce physician appointment length 2. Before transitional care billing the majority of visit would be billed as output evaluation and management visit (99212 - 99215) by meeting requirement health systems can bill code with higher RVU and thus be reimbursed at higher amount 3. Pt managed through interdisciplinary clinic had lower 30 and lower 90 day reshopitalization rate as compared to usual practice d
What are responsibilities of PACT patient aligned car team
1. Managing chronic disease sates like DM, HTN, COPD/asthma/HF 2. Prior authorization drug request 3. Population management
Other special coverage groups under Medicaid
1. Medically needy - individuals with high expenses, 34 states participate 2.Medicare/Medicaid dual eligible - low income medicare eligible with monthly Medicare premiums/cost sharing and long term care
Medicare part d: 2 drug coverage options
1. Original medicare: stand alone prescription drug plan PDP - $13.20 to 120 per month premium in 2021 Deductible 0-435 in 2021 (Usually paired with a medigap plan, but not required, 21 PDPs in Benton county, part D companies regulated by CMS) 2. Medicare advantage prescription drug plan: MAPD where you must enroll in MA part d if offered. Premium 0-201 bundled with medical coverage
Who are exempt from having to pay copays in VA?
1. Service connected disability or condition 2. Catastrophically disabled
Trade offs in choosing drug plan
Choosing one is balancing act between premium deductible, and coverage of your drugs (Ensure your plan includes all current meds at lowest acceptable co-pay, if taking no meds then consider a plan with low premium and high deductible or at $0 premium advantage plan where penalties apply if you have no plan
quick!! medicare part a is WHAT
HOSPITALS
Professional societies
Had key role in regulating their own healthcare industries. Over time, they are rarely direct regulators of healthcare. They're ver influential in deterring what is professional standard and regulatory policy. They have role in accreditation and practice.
Which of the following is not a responsibility of PACT patient aligned care team
Chronic pain management
Provider status
Classification that allows healthcare professional to participate in reimbursement structure aka billing for services provided as allowed by scope of practice
Department of homeland security
Coast guard
Examples of cost sharing
Coinsurance, copays
Which of the following are overseen by the Veterans Health Administration? (SLO 1)
Community living and vet centres
Medigap eligibility
Companies may refuse coverage unless applicant is in guaranteed issue period
Case Study 1: Patients managed through the Clinical Pharmacy Osteoporosis Management Services (CPOMS) were more likely to complete bone mineral density (BMD) sceen or initiate an osteoporosis medication in the 6 months following a fracture as compared to controls. Which statement best communicates the significance of this outcome? (SLO 2 & 4)
Completion of a BMD test or initiation of an osteoporosis medication is a quality measure part of the Five Star Rating System for Medicare Advantage Plans, and thus this impacts plan reimbursement
More wealthy states
Havve less of federal dollar spent FMAP (less than 50% coming from government)
What plan failed?
Health security Plan 1996 but some pieces passed
Oregon birthday rule
For people who already have medigap, it begin 30 days beyond birthday where they can change companies w/o underwriting, change to equivalent plans, and change to plans with less coverage. HOWEVER, they can't change to plans with better coverage
If no SEP, there is penalty for what?
For postponing starting part B. Current premium plus 10% each year delayed and paid for life
Profit is distributed to shareholders in which hospital ownership structure? (SLO 1)
For-profit hospitals
House Bill 2397 , who is it composed of
Formed public health and formulary advisory committee 2 physicians, 2 nurse practitioners, and 3 pharmacists Makes recommendations to board of pharmacy to establish post diagnostic formulary of drugs these include cough and cold product, devices, and continuation fo therapy
How do medicare advantage plans work
Function similarly to employer group plans - gets all medicare covered services from plan's network of doctors -
If an individual misses their initial enrollment period (and is not actively working), then they can enroll in Medicare Parts A and B during which enrollment period? (SLO 1)
General enrollment period
Priority groups of veterans
Group 1 - 50% service connected disability and inability to work, received Medal of Honor Group 2- 30-40% disabling Group 3 - former prisoner of war, Purple Heart medal, discharged for disability, 10-20% disability Group 4 - receiving VA aid and attendance or housebound, catastrophically disabled Group 5- no disability and annual income below limit Group 6- served in Vietnam or Persian gulf, exposed to ionizing radiation Group 7 0 household income below VA adj income limit and agree to copays Group 8- household income above income limit and agree to copays
In which model does the payer (i.e., insurance company) have the greatest control over physician actions, such as prescribing medications, requesting imaging, or placing specialist referrals? (SLO 1)
Group model HMO
Which type of model is known for providing all patient services (e.g., medical office, labs, imaging) in a single location? (SLO 1)
Group model HMO
SEP for medigap
Guaranteed issue for 63 days
Which patient would most likely qualify for community care based on the VA Community Care Criteria? (SLO 1)
Herbert is a veteran of the U.S air force veteran and lives in South Dakota. The nearest VA medical facility is 75 miles away and only provides basic services. He would like to see a community care dermatologist for his severe psoriasis.
Medicare Part A
Hospital (inpatient) insurance -hospitalizaiton, skilled nursing facility, home health care, hospice, blood and no monthly premium with 40 or more work credits (equals to 10 years), skilled nursing care
Medicaid spent by clinical service
Hospital - 34% Community healthcare - 18% Physician and clinical services -14% Administration - 11%
All Medigap plans fully cover.... (SLO 1)
Hospital cost share after the first 60 days
Health insurance portability and accountability act HIPPA
Huge Bill: modernizes the flow of health care info Created the statuary framework for fed government to collaborate with state government to regulate insurance markets
Which agency within the Department of Health and Human Services owns and operates hospitals? (SLO 1)
IHS
What is true about physician charges under Medicare Part B? (SLO 1)
If a physician accepts "Medicare assignment," then they agree to accept the Medicare-approved payment amount for services provided even if it is less than their usual charge for that service.
Which of the following is true about assistance programs that reduce drug costs for Medicare beneficiaries? Note: LIS is also referred to as "Extra Help." (SLO 1)
If someone qualifies for a Medicare Savings Plan (MSP), then they are automatically eligible for assistance with drug costs through a Limited Income Subsidy (LIS).
Which group of individuals would automatically receive their Medicare card in the mail a few months before turning age 65? (SLO 1)
Individuals who are already receiving Social Security retirement benefits.
ICD-10 codes
International statistical classification of disease and related health problems code AKA diagnostic codes. They are used to reimburse hospitals through diagnosis related groups
Case Study 2: Which of the following is true about the impact of adding a pharmacist and social worker to the transition of care process implemented in the University of North Carolina health system? (SLO 2 & 4)
It reduced the number of minutes the physician spent with the patient allowing the physician to see more patients and/or address other patient care issues.
GEP general enrollment period
Jan-March, but effective in July of year you enroll
An individual has a birthday of July 1. If they enroll during the first month of their Initial Enrollment Period (IEP), then when does their Medicare begin? (SLO 1 & 3)
June 1
Medicare advantage health plan
Medicare part C -offered by private insurance companies -must have part a and b but advantage replaces medicare essentially -insurance company receives payments from Medicare trust funds -providers are in networks PPO and HMO defined later (some plans envy payment outside of network) -providers bill insurance company and not medicare -relatively low cost with all these perks, but lots of out of network copayments (further out you leave your zip code)
Workhorse of US healthcare ares system pro's
Medicaid It has flexibility to expand and contract given economic conditions. Has open ended funding that is allowed through fed government. States can't deficit spend like fed gov, so there is plenty to go around from federal government. 73-77% beneficiaries
"Dual eligible" refers to individuals who are enrolled in which two programs? (SLO 1)
Medicaid & Medicare
Medicare Part B
Medical (outpatient) insurance : -outpatient coverage (physician services, preventive services, diagnostic tests, some drug therapies, durable medical equipment, ER, labs, ambulance transport) and standard premium $144.50/month
Medicaid is a program that fills in
Medical tax.
Medigap is short for
Medicare Supplement insurance Not directly billed, provider bills medicare only and then medigap pays provider after notified about plan
Pharmacies
Medicare drug plans work with certain pharmacies. They will send client a pharmacy directory and use plan's pharmacies. Some plans prefer pharmacies utilizing preferred cost sharing Some have mail order
An individual qualifies for a limited income subsidy (LIS/Extra Help). This means that their income is low enough that.... (SLO 1)
Medicare will pay their monthly drug plan premium and any drug plan deductible.
CMS uses PQA measure in star rating for part D programs through these 2 ways
Medication safety - high risk med in elderly, determining appropriate treatment of HTN in pt with diabetes Medication adherence - through proportion of days covered
Waiting period
Medigap can delay 3-6 months paying for a medical cost discovered during 2-6 month look back
Waiting period
Medigap can delay 306 month paying for medical cost discovered during 2-6 month look back
Medicare doesn't cover all gaps. What is used?
Medigap plans which help pay for cost sharing components of original medicare. medicare pays its share of Medicare approved amount and then the supplemental plan will pay all or some of remaining balance.
The front of a medigap policy must clearly identify it as
Medigap supplement insurance OR medigap
What plan expanded psychiatric benefits?
Mental Health Parity Act 1996
Monthly premium and deductible for part b
Monthly premium - 148.50 Deductible - 203
Monthly premium and deductible part a
Monthly premium - 259 if 30-39 quarters employed, but 471 if less than 30 quarters employed Deductible - 1484 for each 60 day hospital benefit period *day 61-90: 371 per day copay *day 91-150: 742 per day copay
Medicaid and medicare cover
More than 1/3 of population
Osteoporosis HEDIS measure
NCQA where percentage of women greater than 67 have a BMD test performed or begin anti-osteoporosis therapy within 6 months of fracture. The report is part of a five star rating system for Medicare advantage plans
Which federal agency is the biggest funder of biomedical research in the United States? (SLO 1)
NIH
Medigap extra benefit
None. plans only cover medicare approved benefits
An individual's Medicare Part A begins on December 1, 2020, but they do not enroll in Part B until February 15, 2021. Assuming they are not covered by an employer group health plan, what is the Part B penalty for late enrollment? (SLO 1)
Not applicable. These dates to not meet criteria for a Part B penalty.
Medicaid finances the majority of care for which group? (SLO 1)
Nursing home residents
A patient has suffered a stroke and needs rehabilitation in order to complete activities of daily living independently. What health profession is she most likely to work with to develop these skills?
Occupational therapist
Open enrollment for medicare
October 15 - December 7
Medicaid and medicare comprise ____ of federal spending
One fourth or 25% Medicaid - 9.3% Medicare - 14.6 %
Highest nations average in Medicare advantage enrolment
Oregon (lots of Medicare advantage opportunities)
Affordable care act
Overarching expansion level of access to healthcare It changed how FPL was calculated (138 —> 400% but they're the same actually) In non Medicaid states, they don't have too meet the ligibilities but are too poor to qualify for market subsidies. More money if you are closer to 138.
Scope of practice
Procedure, action, process that a healthcare practitioner is permitted to undertake in keeping with terms of their professional license
Which of the following is a restriction placed on insurers following passage of the Affordable Care Act? (SLO 2
Prohibits annual and lifetime benefits
Assignment is an agreement between
Provider and Medicare. Patient is caught in the middle
Which program helps people with limited income by paying Part A and Part B premiums, deductibles, co-insurances, and co-pays? (SLO 1)
Qualified Medicare Beneficiary
Health Maintenance Organization Act (1975) HMO
Required employers with more than 25 employees and offering health insurance to include at least one HMO type plan Companion bill requiring all employers to provide a basic health benefit package failed
Which agency is focused on reducing the impact of substance abuse and mental illness on America's communities? (SLO 1
SAMHSA
Oregon experiment outcomes
Saw similar echoes to Rand health. No change in clinical outcomes.No benefit to expanded Medicaid population and saw increase utilization amongst emergency department visits.
(Part 1 of 2) A pharmacist in an outpatient medical office wants to develop a diabetes service. This service will include starting, stopping, and adjusting medications as well as ordering relevant labs. She knows that her state allows pharmacists to enter into collaborative practice agreements with physicians. This information relates to which term? (SLO 2 & 4)
Scope of practice
SHIBA
Senior health insurance benefits assistance (Oregon) State health insurance assistance programs (SHIP)
Deductible
Set dollar amount that a member must spend before a health insurer will begin paying for medical expenses during a given time period (usually one year). Once a patient satisfies a deductible, then they pay EITHER a copayment or coinsurance.
Medicaid enrollees are...
Sicker and more disabled than privately insured
The A1C for a patient with diabetes is elevated. One contributing factor is inconsistent access to healthy food options. Which health professional would be most likely to help connect this patient with resources to address food insecurity?
Social worker
Select the correct pairing: Specialty care: Internal medicine Specialty care: Pediatrics Primary care: Cardiology Primary care: Family medicine
Specialty care: Internal medicine Specialty care: Pediatrics Primary care: Cardiology Primary care: Family medicine
Copayment
Specified dollar amount that a member pays every time a covered service is received (e.g., $50 per hospital admission or $5 per prescription)
Coinsurance
Specified percentage of the cost of a covered services a member pays every time it is received (e.g., 20% of an emergency department visit)
Post affordable care act ...why still so many insured?
Still 30 mil uninsured. Less than 138% FPL and their state did not expand Medicaid, undocumented immigrants, financial hardship exemption is greater than 9.5% income and temporarily at >8.5% per American Rescue Act.
SAIL
Strategic analytic for improvement and learning value model . A system for summarizing hospital system performance within VHA. Information is updated on quarterly basis for all VAMC Quality measures include death rates, complications, pt satisfaction, overall efficiency, physician capacity
Underwriting (medical)
Subscribers are charged different monthly premiums depending on how much medical care they are likely to require using factors like age, sex, geographic location, self-reported health status, and medical history.
What occurs when demand does not come purely from the provider? (SLO 1 & 2)
Supplier-induced demand
What statement explains how the rebate payment to a Medicare Advantage plan with five stars would be calculated under the Affordable Care Act and CMS demonstration program? (SLO 1 & 2)
The plan will get a rebate of 73% of the difference between the original benchmark plus 5% and the plan bid.
Coverage
The risks covered and amount of money paid for losses under an insurance policy If an effect happens, then the insurance company will make payment to the policyholder (or similar entity) to cover all or part of the resulting loss
Which is a characteristic of the Bismarck Model? (SLO 1)
The system is financed jointly by employers and employees.
This statement is correct for an individual turning age 65, but who is still working and covered by an employer group health plan (EGHP) with creditable prescription drug coverage? (SLO 1)
They can voluntarily enroll in Part A and/or Part B while still covered by their EGHP, but they are allowed to defer either without penalty.
A patient, who is now 70, enrolled in Medicare Part A and B plus a Medigap Plan F at age 65. What correctly applies to this situation?
They will have no co-insurance for Medicare Part B services regardless of whether the provider accepts assignment.
Insurance company cannot refuse
To issue you a Medicare supplement policy when you are in your initial enrollment period. You have 6 months after part b
IEP for medigap
Up to 6 months after enrolling in part B
In the NPR Planet Money episode "The Debt Ceiling, Obamacare, and Welfare," what term was used to describe the outcome of a failure to mitigate adverse selection? (SLO 1 & 2)
death spiral
Out of pocket max =
deductible + copayments + coinsurances
Tri-Care
department of defense program to provide health insurance to active duty military members and some military retires and their dependents
medigap other costs
few copayments or coinsurance. only covers medicare approved charges
the new medicare card has what info
full name medicare number entitled to: and coverage date *NO SSN*
general enrolment period
if they miss or do not qualify, they wait until GEP here. this lasts from jan 1 to march 1 with coverage beginning july 1st. beneficiaries may experience late penalties
starting part b late
if you or spouse actively working, you are entitled to SEP (special enrolment period) for part b you have up to 8 months from loss of group plan to enroll in part b by completing CMS form 40-b and get CMS form l-564 from employer's HR department
COBRA and medicare and turning 65
if you're on COBRA, you gotta apply for medicare at 65
The NPR Planet Money episode "Can Hospitals Save Monday by Making Doctors Squirm" relates to which risk topic? (SLO 1 & 2)
incentives to create losses
subscriber
individual who purchases policy
medigap provider choice
individuals may see any provider that accepts original medicare
beneficiary or member
individuals on the policy
Advantage plan extra benefits
may provide additional benefit (dental, hearing, vision) May be included within premium or for an additional monthly fee (rider)
premium
money paid to purchase policy (monthly fee)
Turning 65 and don't know what to do
must be proactive and apply to social security administration to start medicare on time w/o penalty.
Medigap drug coverage
not included, patient will need a stand alone part D plan
dependent
other individuals on policy (spouse, domestic partner, children)
QUICK!! MEDICARE PART B IS what??
outpatient
Inpatient
patient stays in medical facility for at least one night (hospitals, mental institutions, nursing homes) patient is examined, diagnosed, or treated at a medical facility, but don't stay overnight
PCAB
pharmacy compounding accreditation board. It is voluntary accreditation. There's been movement in what quality standards look like.
Medigap premium cost
plays may underwrite applicant outside of a GI period. premiums vary with gender, age, health status
Medicare advantage plans
private companies manage individual's medicare benefits. they're different from original medicare + medical in cost sharing structure because individuals pay as they go through copays/coinsurances to an out of pocket maximum. for patients, these are a lot like employer group health plans
Advantage plan drug coverage
provided by advantage plan in most situations
advantage plan provider choice
provider network, generally in form of HMO, PPO
Indian health services
provides health care for native americans and alaskan natives
special enrolment period
without penalty they had coverage through were active employer or spouse individuals have 8 months from when employer ends in order to enroll for medicare
if you are still working and want medicare
you can defer starting part b and d until you retire -employer plan pays first -reccomended to start part a when 65 b/c there is no premium -exception: recommend to start both part a and b when turning 65 if fewer than 20 employees or self employed (med plays first, employee pays second)
What drugs are not covered
• Prescribed for weight-loss or weight-gain. - Anabolic steroids are covered. • Most prescription vitamins • Over-the-counter drugs (except insulin) • Fertility drugs • Cosmetic drugs • Erectile dysfunction drugs
Which statement correctly describes a staff/group-model HMO? (SLO 1)
Physicians risk termination based on their performance.
Which of the following is NOT a type of Medicare Advantage plan? (SLO 1)
Plan C
Cost for medigap varies by:
Plan, age and gender, zip code
Must have both part a and part b
to enroll in medigap or medicare advantage plan
Which of the following does NOT contribute to a patient's out-of-pocket maximum? (SLO 1)
Premium
Employer sponsored insurance - con for employer?
Premium shave been increasing faster than wages and inflation.*
Which of the following is a correct match between country and health-system model? (SLO 1)
United Kingdom, Beveridge Model
What privileges do VA pharmacists have
Prescriptive authority (write own prescriptions and start stop and modify therapy) can be licensed in any state, order and monitor labs
Medicare advantage premium cost
all plan payers pay same premium
quick!! advantage plans?
also known as part c can include prescription drugs
CPT codes 99605 - 99607
are codes that allow pharmacists to bill medication therapy management services under Medicare part D
In order to provide care for 2500 patients
Doctor would have to spend 18.7 hours per day on healthcare
Coverage gap or donut hole of part D
- client and insurance company pay combined 4430, then client pays up to 25% copay for all drugs (70% of cost by manufacturing)
If you move to another zip code and enroll in medigap first time within 90 days w/o underwriting, even if initial guaranteed issue period passed
False, it's 63 days and not 90
People receiving extra help via LIS have a continuous special enrollment period. T/F:
False, there is no time limit to get LIS help
Certain groups of people automatically qualify for extra help with medicare prescription drug costs and don't have to apply T/F:
False: they don't just give it you, you have to apply
What is the mechanism that Medicaid relies on to achieve the "best price" for pharmaceuticals? (SLO 1)
Federal and state rebates
Part B enrollment period
-Same 7 month period when first eligible -Jan-march each year part b becoming effective July 1 (permanent 10% premium increase each 12 month delay) -up to 8 months after active work (self/spouse) or employer group health plan (whichever happens first) -EGHP's are acceptable coverage
FMAP
Federal matching assistance percentage Depending on wealth or per capital income, determines how much federal support they are given On average, 57% (0.53) of every dollar spend to operate Medicaid is from federal government . The state pays fro reminder of that or 43% (0.43)
Medicaid fills the gaps
For low income beneficiaries. Most of coverage that it provides is for long term care because of coverage gap in medicare program.
Which health profession often works outside of traditional healthcare settings to reduce the risk of noise-related hearing loss?
Audiologists
Medicare - WHen does coverage begin if you apply 3 months after you turn 65
Begins 2-3 months after
Medicare - When does coverage delay if you apply the month of 65th birthday
Begins first day of month following birthday
Medicare - When does coverage begin when it's 3 months before the month you turn 65?
Begins first day of month you turn 65
What is a beneficiary?
Beneficiaries on a health insurance policy are either subscribers or dependents.
Financing of Medicaid is the responsibility of... (SLO 1)
Both state and federal governments
Which health professional cannot prescribe medications in most states?
Chiropractor
Whole person theory
Disability rating can never be 100%. Uses combined rating table. Start with highest disability percentage, high to low. 38 CFR 4.25.
Medicaid enrollees
Disabled - 15% Elderly - 10% Adults - 25% Children - 49%
Medicaid expenditures
Disabled - 43% Elderly - 25% Adults - 13% Children - 20%
why should someone choose medigap plan or medicare advantage plan?
------
Paying for part b premium
-2 ways to pay (deduct from SS pension check, and if not receiving SS, CMS will bill quarterly) -low income who qualify for Medicaid can have premium paid by state
eligibility for medicare
-65 and older -don't need to be retired automatically enrolled if receiving SS benefits (otherwise apply through social security and not through medicare) OR -under 65 receiving SS benefit for 24 months (auto-enrolled). no waiting period for those with end stage renal disease, ALS, or early onset alzheimer's
Employer sponsored insurance - pro for the patient?
-An employment benefit not subject to income taxes -Much lower premiums (as compared to individual plans) -(1) the employer contribution and (2) large number of policies sold (economy of scale) -Employer plans generally cover pre-existing conditions
Employer sponsored insurance - pro for insurance company?
-Captive consumer -Access to a healthy population --> Links to adverse selection
How do Medicare advantage plans work?
-Function similar to employer group plans -generally patient gets all medicare covered services from the plan's network of doctors -pt uses advantage plan card and not medicare card. If MD bills medicare, then the change will be denied -copays for office visits $0-40, and hospitalization ($100-300/day for 4-5 days) -copays or 10-20% for labs and procedures -usually includes medicare part D prescription coverage -extra benefits included like vision, hearing, and gym membership
Guaranteed issue periods of medigap
-IEP initial enrollment period : up to 6 months after enrolling Medicare b, once six months begun, can't be stopped -SEP special enrollment period (guarantee issue for 63 days) where disabled are turning 65 even on Medicare, person loses coverage for no fault of their own ( EGHP ends, retirement, moves out of service plan area, loss of Medicaid, first 12 months in medicare advantage plan at 65, current plan insurer leaves service area)
Individual private insurance
-Less comprehensive -More expensive in both premiums and cost sharing -Less accessible as payers could discriminate based on risk -Initially, all individuals were required to get health insurance or pay a penalty ("individual mandate"). The insurance exchanges were a strategy to achieve this requirement. -Payers could no longer discriminate based on risk (medical underwriting) for most plans. - Allowed dependents to stay on parent's policy until age 26
Employer sponsored insurance - con for the patient?
-Limited choice of insurance options -Decreases mobility
Employer sponsored insurance - con for insurance company?
-Lower premium rates (as compared to individual plans)
What is medigap plan
-Medicare supplement insurance sold by insurance companies (must have Medicare a and b ) that fill gaps in original Medicare -plans tend to have nationwide coverage (there are exceptions, when moving) -compare premiums - vary for same coverage -no drug coverage unless part d plan also purchased (exception PERS MODA supplement, and some other union/federal plans
Part D costs
-Monthly premium which varies each year -annual deductible up to 445 -initial benefit period after deductible (25% copay on average) -coverage gap or donut hole - client and insurance company pay combined 4430, then client pays up to 25% copay for all drugs (70% of cost by manufacturing) -catastrophic coverage: after client pays 7050 out of pocket, client pays max copay of up to 5% or 3.70 generic/9.20 for brand
Part b (medical/out-patient coverage)
-Monthly premium ~148 for most people in 2021 -Higher premium if higher income -$203 deductible -medicare pays 80% of med bills, lab test, x ray, scans, other procedures -penalty if don't enroll unless covered by employer. VA/COBRA are not acceptable waivers -low income subsidy available
HMO PLAN
-Must choose primary care provider (need referral to see specialists) -must get care and services from plan's network (only doctors and hospitals that contract with the plan, they pay full for care outside plan's network, usually covered emergency or urgently needed care) -special needs plans for low income (SNP)
What is true about Oregon's implementation of Medicaid?SLO 1)
-Oregon has created a prioritized list of services to determine Medicaid coverage. -Oregon's Medicaid program is named the Oregon Health Plan. -Oregon uses a network of managed care organizations to deliver Medicaid services.
Which drugs are covered
-Prescription (brand and generic, plus specific drugs covered vary by insurance plan) -drugs, biological, insulin (flu shots, hep b, pneumonia , tetanus treatment are part of B) -blood sugar tes strips and lancets part B *injectable drugs in doctor office or infusion center are part B and 20% copay -all other vaccines (hepatitis A, shingles tetanus prevention part D) -insulin, syringes, needles part D
What is true about the evolution of health insurance in the United States?
-The Baylor Hospital Partnership exchanged a set number of hospital days for a prepaid fee. -Early forms of health insurance were more similar to current disability coverage because they focused on lost wages rather than medical care expenses. -Passage of the Affordable Care Act represented the largest legislative expansion of health care since creation of Medicare and Medicaid. it is NOT the following: Major health care reform efforts were omitted or blocked as part of Franklin D Roosevelt's "New Deal," Harry Truman's "Fair Deal," and Lyndon B Johnson's "The Great Society."
Limited income subsidy LIS
-administered by social security for prescription drug assistance only -enroll at SSA.GOV -Rx copay - 3.70 generic, 9.20 brand
Catastrophic coverage
-after client pays 7050 out of pocket, client pays max copay of up to 5% or 3.70 generic/9.20 for brand
TripleAim
-also goes by quadruple aim or iron triangle -simplified to Cost, Access, and Quality -is a framework to optimize health system performance 1. improves patient experience of care (quality and satisfaction) 2. improving the health of populations 3. reduces the per capita cost of health care
Medicare advantage PPO plan
-can see any doctor or provider that accepts medicare (not required to designate PPP, given a list of in-network providers, don't need referral for specialist, don't' need referral for out of network, and copays and coinsurance are set by the plan)
CHIP (a special category of Medicaid)
-expansion of Medicaid to low income children whose needs exceed traditional Medicaid -enhanced state matching -capped allotment (block grant) -9 mil children enrolled
Medicare savings plan (MSP)
-full dual, QMB, SLMB/SMB, QI/SMF -Medicaid plans administered by states -pays medicare part b premiums -depending on income, may pay medicare deductibles and copays. Dual eligible -all qualify for LIS
Other medigap rules:
-if you apply for medigap plan outside of guaranteed issue period, you'll be denied because of pre-existing medical issues -Oregon's birthday rule: people who have medigap, beginning on person birthday and 30 days beyond birthday( can change companies, equivalent plans, plans with less coverage) and cannot change to plans with better coverage
Impact of affordable care act
-if you are a small employer, you receive tax credit if you offer insurance and there are strategies for small group employers to come together and purchase insurance policies
Special enrollment periods
-if you move out of plan's service area (63 days) -if plan leaves service area (63 days) -if you qualify for extra help (continuous enrollment) -if employer coverage ends or you quit working (whichever happens first - 63 days) -starting or changing to a five star advantage plan
Pre-existing look back period
-limit unwriting allows medigap plans to obtain clients med history 2-6 months prior to effective date of policy *look ack not permitted if client had continuous coverage prior to enrollment (ACA, OHP, COBRA, EGHP, VA)
Items not covered by Medicare (but by private insurance)
-long term care -routine vision and dental care (some eye and dental surgeries covered) -hearing aids -private duty nursing -nonprescription drugs - only if have part d and advantage plan with part D -mostly supplement/naturopathy -acupuncture -limited chiropractic treatment(subluxation) -services outside the US
Advantage plans
-lower premiums -have copays and annual deductible -limited doctor networks by geographic area (hMo more strict than PPO) -includes drug coverage -may waive 3 midnight rule -may allow annual physical exam -varying out of pocket physical exam -varying out of pocket maximum per year -usually extra benefits
COBRA
-not an insurance option -consolidated omnibus reconciliation act of 1985 Not truly a source of insurance. It is a law that allows individuals to retain their employer sponsored insurance for up to 18-or 36-months following loss of coverage. Subscriber is responsible for full monthly premium
Veterans Health Administration
-part of the us Department fo Veterans affairs (VA) that -provides medical care to veterans and thei rfamilies at low or no cost -operate outpatient clinics, hospitals, and long-term care facilities
Assignment
-payment agreement with providers for part B -if providers accept assignment, they agree to bill Medicare for services provided by Medicare beneficiary, accept amount Medicare approves for services in full -beneficiary limited to 20% Medicare approved charges -be sure provider accept Medicare (they can opt not to take or bill Medicare. Pt would pay full cost at MD charged rate)
What are the mandatory items covered by Medicaid
-physician -inpatient/outpatient stuff -health center services (rural and federally qualified) -nursing facilities (for 21 and over) -lab,x-ray -early and periodic screening, diagnostic, and treatment EPSDT services for individuals under 21 -family planning -nurse midwife services
What does part b pay for again? 80% for
-physician service -outpatient medical and surgical procedures -outpatient mental health services -lab and diagnostic test -physical and occupational therapy -durable medical equipment (DME) and diabetes supplies -part B injectable drugs given in doctor's office or infusion center (cancer chemotherapy, some asthma, and auto immune drugs) -preventive health care services (some are free) -pay20% without private insurance
Medigap plans cost
-premiums increase with age Plan g: part b deductible only, no other copays for medicare approved services. Some plans have deductibles or co-pays. -nationwide coverage (if MD takes medicare patients) but may be harder to find PCP -no drug coverage except PERS -no annual physical -3 midnight rule (3 midnights in hospital for inpatient you could be admitted to skilled nursing for rehabilitation) -no extra benefits
Optional Medicaid coverage items
-prescription drugs —clinical services -dental service, dentures -PT and rehab -prosthetic, eyeglasses -primary care case management -intermediate care facilities for mentally retarded -inpatient psychiatric care for individuals under 21 -home health care services -personal care services -hospice services
What are examples of reimbursement through a "defined criteria?" (SLO 1)
1. capitation 2. salaried physician 3. diagnostic related groups
Medicare part b penalties
10% of part b premium for each full 12 months as individual could have been enrolled in medicare
___ states in country that did not expand Medicaid
14
VA - disability claim make take an average of
144 days to complete disability related claims
Family first coronavirus response act and the out come of it
1st stimulus package at start of pandemic. Increase FMAP by 6.2 percentage points for everyone. Fed gov provided significantly more investment to expand Medicaid program from few 2020 to may 2020, enrollment increased by 3.2% but there was lots of variation
MISSION act
2018. Goal to give greater access to vets and expand benefits. Improve VA disability and recruit and retain their medical providers. Additional access for compressive assistance to family caregivers these veterans are improved for community care. Telepath. Urgent and walk in care. Appointments with non VA providers. Use with IHS or tribal health plans.
late enrolment in medicare
3 months after turning 65 general enrolment jan - march
applying to medicare
3 months earlier, delayed until first day of month following birthday, and up to 3 months after month you turn 65 which delay (initial enrolment period) -you missed enrolment period then you can enroll jan - march, but it is effective only in july (general enrolment period)
Approximately what percentage of veterans have at least one disability?
30%
What percentage of VA pharm share advanced practice providers
45%
Managed care. What amount of spending from Medicaid? Long term care. What amount of spending from Medicaid/
49%, 20%
Initial enrolment period
7 month period when individual is first eligible medicare (7 month hug)
Medicaid covers
73 million or 1 in 5 individuals
What are the CPT codes
99495 - 99496 - Provide care management and care coordination . They are current procedure terminology codes or procedural codes. Determine amount of money practitioner makes upon specific service. They link to relative value units (RVU) which translates to money
Policy
A contract that specifies what risks are covered and how much will be paid for losses
As currently implemented in the United States, what is an insurance exchange? (SLO 1 & 2)
A federal or state run "marketplace" where qualifying individuals and small businesses can compare and purchase health insurance.
The big picture or value based reimbursement
A lot of different services that might below quality. How do we pick and choose to find higher quality care at lower cost
During the annual enrollment period (October 15 - December 7)... (SLO 1)
A person can change to a different Medicare Advantage or stand-alone Part D plan without underwriting or penalty.
In addition to CMS, this federal agency is a major funder of Oregon's Senior Health Insurance Benefits Assistance (SHIBA) program, as well as similar programs in other states (a.k.a., SHIP)? (SLO 1)
ACL
ACO
Accountable care organization - system of delivering care to patients and of receiving payments from insurers A medical neighborhood that includes primary care providers, specialty providers, and hospitals. Coordinate within an integrated infrastructure and emphasize primary care. Reward for positive outcomes and penalize for negative outcomes
CMS set price on most amount of money for insurance company to cover certain amount of Medicare beneficiaries in specific area
Additional bonus payments for 4 star plan Plans can bid and based on star rating, you get rebate back! = 73%. However there is new benchmark adjusted because of reform law and cMS demonstration (adjusted by 3%). Rebate changes based on number of stars
Primary care mental health integration PCMHI pharmacist may perform what
Administer questionnaires such as PHQ-9, GAD-7, PCL-5
What best describes the status of the United States healthcare system?
After substantial growth, healthcare spending has stabilized around 18% of gross domestic product (GDP), but it is still slowly rising.
Choosing a plan
All plans have similar drug groups but vary by specific drug class and copay 1. Collect info 2. Compare medicare drug plans 3. Call plan with any questions
community rating
All subscribers pay the same monthly premium.
SomFlexiblity for premiums and cost sharing with Medicaid
Allowed for individuals above 100% FPL -Working individuals with disabilities -those covered under 1115 waivers
Employer sponsored insurance - pro for employer?
An employment benefit not subject to income taxes
Which statement is true about Medigap policies?
An individual must have both Part A and B to purchase a Medigap policy.
Which is the primary enrollment period for beneficiaries to change their Medicare Advantage or standalone Part D plan? (SLO 1)
Annual enrollment period
Which group became newly eligible for Medicaid in certain states in 2014? (SLO 1)
Anyone with an income less than 138% of the federal poverty level
If you miss enrollment period, this is when you apply
Apply during General enrollment period (Jan - March) Coverage effective only in July The penalty for part B premium is 10% per each 12 month period starting with birth month, you pay this penalty as long as you have part B, and you have limited exceptions
4 branches of department of defense e
Army, navy, marines, Air Force
What describes employer-sponsored insurance? (SLO 1)
As health insurance costs rise, employers are shifting more costs to employees, primarily by increasing the cost sharing burden to employees
This agency within the US Department of Health and Human Services administers the Medicare program. (SLO 1)
CMS
Triple aim again?!
COST! ACCESS! QUALITY!
Providers who don't accept assignment
Can charge as much as they wish
Specialty area of VA pharmacist?
Cardiology, psychiatry, informatics
What is a risk management solution to moral hazard? (SLO 1 & 2)
Cost sharing
What is medicaid?
Coverage for families and individuals with low income and resources
What is medicare?
Coverage for qualifying Americans aged 65 and older, younger individuals with low income and resources
Medicare Part B... (SLO 1)
Covers influenza and pneumococcal vaccines.
(Part 2 of 2) A few months pass and the pharmacist is regularly seeing and managing diabetic patients, but insurance claims are frequently not paid to the clinic. It is learned that that most payers will reimburse pharmacists for clinical services delivered in an outpatient medical office. However, many payers require advanced training, either through a residency or board certification. This information relates to which term? (SLO 2 & 4)
Credentialing
HEALTHCARE RESEARCH AND QUALITY
DHHS Find healthcare effectiveness and cost
If you are still working at 65 and have EGHP with creditable medical and RX coverage, you can
Defer starting part B and Part D until you retire Employer plan pays first Start part A when 65 bc no premium Exception is that you start both A and B when turn 65 bc fewer than 20 employees or self employed. Then medicare pay first and employee pay second
CCO
Determine if this is effective at improving care, making more accessible and limiting healthcare disparities
Which statement is true of the Medicaid outpatient pharmacy benefit? (SLO 1)
Each state sets their own prescription drug reimbursement policies.
Fully insured
Employer buys insurance from a private company for its employees. The insurance company is the payer and assumes the financial risk. If there is profit, then it goes to the insurance company. Regulated by state governments.
Which statement correctly describes the nursing profession?
Examples of advanced practice nurses include nurse practitioners, clinical nurse midwives, and nurse anesthetists.
Transition of care - stick
Excessive readmission penalties
The part b premium for most people in 2021 is $203: T/F
FALSE
Medigap initial open enrollment period is
Lasts for 6 months; begins when you are at least 65 and begin enrollment in part b
VA - among of basic benefit paid is dependent on
Level of disability . VA decide severity of illness or jury. Rate goes form 0 - 100%. Example: 10% disability rating - monthly pay is 144.14 20% disability rating - monthly pay is 284.93
Per existing look back
Limited underwritten allow medigap plan to obtain client medical history 2-6 month prior to effective date
A patient has been hospitalized for severe burns following a house fire. His condition has stabilized. However, he will require several weeks of sophisticated wound care, including daily dressing changes with sedation. What type of facility is he most likely to receive this care upon discharge? (SLO 1)
Long term acute care hospital
Which group of individuals might qualify for premium-free Medicare Part B? (SLO 1)
Low income individuals who qualify for financial assistance through their state's Medicaid program.
Which of the following are uniformed services within the U.S. Department of Defense? Note: Multiple answers may be possible for this question. (SLO 1)
Marines & Navy
States can opt in and opt out
Medicaid
PQA
PQA - pharmacy quality alliance. Value based reimbursement where there is alliance of greater than 130 member organizations including health plans and PBMS, professional associations, federal agencies, manufacturers, and consumer advocates. Mission to improve quality of med management. Improve pt health through collab process and implement performance measure. Recognize example of exceptional pharmacy quality. Has been adopted within value based reimbursement program. A good consensus medication safety alliance.
Comprehensive coverage is done 2 ways:
Part A + Part B + Medigap + Part D OR Medicare Advantage Part C
The Medigap plans discontinued in 2020 for newly eligible beneficiaries uniquely covered which gap in Original Medicare? (SLO 1)
Part B deductible
How much medigap cost
Part b premium + medigap premium + part d premium -depends on age, smoker/non smoker, gender, zip code -premiums can increase twice in one year as you age
What was a conclusion of the Rand Health Insurance Experiment? (SLO 1)
Participants with any cost sharing (i.e., 25 - 95%) had similar rates of hospital visits per year.
What if prescription changes
Patient and doctor should work with plan, finding drug that is on formulary If drug needed is not on formulary, can request an exception. If plan denies exception request, can appeal and use transition fill during the appeal Consider changing plan next year that does have desired drug
CPOMS
Patients were evaluated for compliance with NCQA Jedi's measure for post fracture care. Based on appropriateness, recocmendtIONS were developed later and to immediately start treatment with a medication. PCCPS colllabed with PCP to implement plan
CMS reduces
Payments to hospitals with excessive readmissions. In 2013, CMS reduced payment to hospitals defined as excessive rehospitalizations. Reducing payment meant no reimbursement to hospital for secondary readmission within 30 days. Reduces reimbursement for up to 3% of all payments.
RAND HEALTH EXPERIMENT outcomes
People got Free care or very little coverage. Free plans = higher hospitalizations as compared to having cost sharing Cost sharing - No impact on how negatively impacted car received
Public health insurance programs include all of the following
TRICARE IHS CHIP
T/F: at the federal level, pharmacists are not recognized as providers
TRUE
TRUE/false: veterans must receive approval from VA prior to obtaining care from community provide r (most circumstances except for emergency service)
TRUE
Which statement describes a similarity between Taiwan's health-system and another county as presented in Sick Around the World? (SLO 1)
Taiwan's system is financed through premiums jointly paid by employers and employees similar to Japan.
Which of the following is driver for the shift in care from the inpatient to outpatient environment? (SLO 1)
Technology advancements expanding the scope of services that can be safely provided in an outpatient setting.
If a person signs up for Medicare Part A, but not Part B, while still covered by an employer group health plan (EGHP) with greater than 20 employees, then... (SLO 1)
The EGHP acts as the primary payer and Medicare acts as the secondary payer for hospital care.
Which of the following describes a deductible? (SLO 1)
The amount an individual pays before an insurance company begins paying in benefits.
Case Study 3: Which of the following best describes the role of the pharmacist within the physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients? (SLO 4)
The pharmacist was responsible pre-interviewing the patient before initial and follow-up appointments. The pharmacist would then present a summary to the physician to facilitate treatment planning.
Self insured
The employer contracts with a private company to handle the day-to-day administration of an insurance plan. The employer acts as payer and assumes the risk. If there is profit, then it goes to the employer. Regulated by the federal government.
Drug coverage violates which principle of insurable risk? (SLO 1)
The event must result in a substantial loss.
Which statement is true of the Medicaid expansion in 2014? (SLO 1)
The federal government funds at least 90% of the Medicaid expansion population.
Transitions of Care
The movement of pt from one setting of care to another usually hospital to an inpatient care facility or home
Which country's health-system is funded through tax revenue? (SLO 1)
United Kingdom
Pharmacy coverage is an exception....
To traditional insurance principals because the event must result substantial loss. We adjusted claims for very cheap generic drugs. Why would pharmacy still pay for those claims? Drug therapy is preventative in nature. From a health insurance perspective, it results in preventing larger cost in the future because of it being preventive. So, there is overall decrease in cost.
Transition of care - carrot
Transitional care management CPT codes effective since 2013 . The goal is to provide reimbursement for care management and care coordination. Develop innfratsure that will prevent penalties from happenings
After 120 days
Treasury may offset social security. Then va not able to provide debt assistance
T/F: federal law limits what states can charge to nomainla amounts
True
Once initial 6 month medigap IEP starts, it can't be changed
True, initial 6 month medigap IEP cannot be changed once started
People with lowest income and resources will pay no premiums or deductibles and have small or no copayments for part d coverage: T/F?
True, they get premium and deductible paid
Which county uses a Beveridge Model? (SLO 1)
UK
Risk is uninsurable when
Unanticipated and pure
Pharmacy services can be reimbursed under this Medicare Part ___ if provided in areas that are medically underserved, and have shortage of health professionals in the area. Establishes pharmacists as a healthcare provider
Under part B, amends section 1861 of the social security act HR 2759
After 90 days of no payment
Va benefits
Credentialing
Verification of experience, expertise, and willingness to provide care that allows healthcare professional to be reimbursed by a specific payer
Which of the following is strategy employed by health payers to mitigate adverse election? (SLO 1 & 2)
Waiting periods
Which state allows pharmacists to obtain registration numbers from the Drug Enforcement Administration (DEA)? (SLO 1)
Washington
When comparing PPO Advantage plans to HMO Advantage plans... (SLO 1)
While both HMO and PPO plans have limited provider networks, PPO plans allow the patient to see out-of-network providers for a higher cost share.
Can you enroll in medicare part A without part B ?
YEAH
Can pharmacists prescribe controlled substances? (VA specific)
Yes if they are LaCie send in specific state and have DEA number (CA, Montana, WA, Idaho)
SEP special enrolment period
You or spouse actively working, you are entitled to this when you retire or lose employer plan Part B you have 8 months to enroll For medigap or advantage, you have 60-63 days to enroll in plan after loss but need part B
Medigap plan
You're pretty sick
Advantage plan
You're probably healthy but you're gambling
Medicare advantage star ratings
` existed prior to affordable care act , put a lot of incentive in accelerating the movement towards value based reimbursement programs. In 2012, they began 3 year demonstration program to assess impact of quality measure and plan rating on delivery of care.
cost sharing
beneficiary still responsible for portion of cost
CPT codes 99212 - 99215
billed as output evaluation and management visit
Staff model HMO
characterized by health maintenance organization owning the health care facilities and directly employing physicians
Group model HMO
characterized by one contract between HMO and one physician group. Physicians offer services exclusively to HMO pt and are reimbursed on a capitated basis
advantage plans other costs
copayment or coinsurance required for most services. pay an out of pocket maximum
Medicare advantage plan eligibility
required to take applicant who lives in service area
medicare part d
standalone prescription drug plans
