6012 Final Review

Medicare Part A Hospital/Inpatient Deductible (What the beneficiary owes)

$1340 deductible for each benefit period Days 1-60: $0 coinsurance for each benefit period Days 61-90: $335 coinsurance per day of each benefit period Days 91-beyond: $670 coinsurance per each "lifetime reserve day" after day 90 for each benefit period Beyond lifetime reserve days: all costs

1/4 Medicare beneficiaries spent at least ______ per year spending on Medicare

$6,400

Describe the basic benefits of CHIP

- "Actuarial" benefit design, with limitations and exclusions permitted - State-designed benefit packages, but requires well-baby and well-child care, including age -appropriate immunizations, lab and x-rays, inpatient and outpatient care, and dental - Mental health parity requirement with medical and surgical benefits, if state covers MH/SA services - Option to provide dental-only supplemental coverage for children who have ESI without dental benefits but otherwise qualify for CHIP - vision and hearing optional

List and describe some of the provisions made by ACA to improve Medicare quality, efficiency, and transparency

- Center for Medicare and Medicaid Innovation (CMI): supports the development and testing of innovative health care payment and service delivery models - expansion of existing Medicare value-based purchasing demonstration projects - disclosure of financial relationships between health entities required - reduced payments for hospitals with high readmission rates - bonus payments for high-performing MA plans

FFS vs. Managed Care

- Delivered through different financing mechanisms and settings - Fee-for-service - States set provider payments under fee-forservice consistent with efficiency, economy, and quality of care - Rates lower than those paid by other payers

Understand NFIB v. Sebelius

- In a 5-4 decision issued June 27, 2012, the Supreme Court upheld the individual mandate as constitutional under the Constitution's Taxing and Spending Clause - The Supreme Court also ruled that the federal government could not withhold all medicaid funding if the states decided not to expand medicaid

Part A: Benefits

- Inpatient hospital care - Skilled nursing facility (SNF)— post-acute care - Hospice - LONG TERM CARE NOT COVERED

Traditional Medicaid: Does not cover

- Low-income adults without disabilities - Women who are not pregnant - Near-poor - About 30 million low-income individuals left uninsured

Describe federal allotments for CHIP

- Originally financed by $0.62 increase in federal cigarette tax - Federal funds allotted to states based on recent CHIP spending, adjusted annually for child population growth and medical inflation - States have 2 years to spend on each allotment: * unspent funds can be redistributed to other states with shortfalls * states that use allotted funds and exceed target enrollment are also eligible for contingent fund payments - Federal government provides matching funds like Medicaid but federal funds are capped for each state - Reduced matching from federal government for covering children over 300% FPL

What does the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) do?

- Prohibits Medicare supplemental insurance (Medigap) policies from covering the Part B deductible for people who become eligible for Medicare on or after 01/01/2020 - Repealed SGR, averting 21% cut to doctors; gave doctors 0.5% increase for the next five years as Medicare transitions to a system designed to pay based on value instead of volume - Under the new QPP (Quality Payment Program), doctors choose either MIPS or APMs (alternative payment models)

Describe trends and growth in Medicaid over time

- Started as a social program to ensure health care benefits and legal protections to vulnerable populations - Grown, especially under ACA, with medicaid expansion

What flexibilities do states have in designing their Medicaid programs?

- They need to meet federal requirements, but they do have flexibility in designing their medicaid program - States can apply for medicaid waivers to test out certain programs - Proposals must be budget neutral, follow MOE rules

What are the optional benefits benefits of traditional Medicaid (pre-ACA)?

- acute care benefits (i.e. Rx drugs, medical/remedial care by non-physician, rehabilitation and other therapy, clinic services, dental services, DME, prosthetics, eyeglasses, primary care case management, TB services, etc.) - long-term care benefits (i.e. intermediate care facilities for mentally retarded, inpatient/nursing facilities in mental disease institution, inpatient psychiatric hospital, home/community based waiver, home health care, targeted case management, respiratory care, hospice care, PACE)

What is the part D donut hole?

- coverage gap! - first, you pay your $275 deductible - then you pay 25/75% coverage (enrollee pays 25%) - this goes up to the first $2510 a drug costs - once you hit $2510 in total drug costs you hit the DONUT HOLE-- you have NO COVERAGE (enrollee pays 100%) - you keep paying the premiums but you don't have any coverage - once you hit $4050 out of pocket ($5726 total drug costs), then catastrophic coverage kicks in and enrollee pays 5%, the plan and medicare pay the other 95% (plan pays 15%, medicare 80%) - resets when the next year rolls around

What is medicare Part C and what does it cover?

- covers managed care/medicare advantage - voluntary (25%) enrolled - patients enroll in private managed care plan, then parts A and B pay the insurance company - part C replaces parts A and B, you cannot have both - comprehensive coverage, usually includes prescriptions - can restrict providers/networks, may offer additional benefits, limits out of pocket spending (around $4k limit) - so, in turn for accepting restrictions of managed care plan under part C, you may get expanded benefits and lower cost sharing if you get sick and less co-pay in hospital

How do providers get paid?

- define products and services medicare is buying, set relative values (for individual services or bundles of services) for services to be provided, make adjustments - adjustments: providers get more or less reimbursement depending on their participation in other services (like DSH, GME, PQRI, etc.) - DSH = disproportionate share hospital- GME = graduate medical education - PQRI = do quality improvement- prospective payment: release list of services they will pay for and how much they'll pay

What are other types of supplemental coverage?

- employer-sponsored supplemental coverage plans- about 30% have such coverage (less common than Medigap) - Medicaid helps pay for Medicare's premiums and cost sharing for 20% of Medicare beneficiaries with low incomes and modest assets (known as "dual eligibles"). - Medicare Access and CHIP Reauthorization act (MACRA): prohibits Medicare supplemental insurance (Medigap) policies from covering the Part B deductible for people who become eligible for Medicare on or after January 1, 2020.

What is medicare part A and what does it cover?

- hospital insurance - mandatory enrollment (no premiums)-- if you are 65 you are automatically enrolled in part A - paid for by medicare hospital insurance trust fund - benefits: inpatient hospital care (acute care after surgery, etc.), skilled nursing facility (SNF), hospice - LONG TERM CARE NOT COVERED

What is the moral hazard concern with Medigap?

- it will drive up utilization of doctor visits because it is less cost so people will go more - people may be paying more each month than they really need because they're paying for additional insurance just in case

What are some key characteristics of Medicare Part A?

- mandatory enrollment without premiums (paid by the Hospital Trust Fund; funds taken from income tax) - benefits include inpatient hospital care AND skilled nursing facility (post-acute care and hospice); *long-term care (i.e. nursing homes) are NOT covered - cost sharing kicks in for hospital care after 60 days and for skilled nursing facility care after 20 days

Who are the medicare enrollees? What is the trend?

- non-elderly disabled, and elderly on medicare - more of US enrolled in medicare, and staying on medicare longer (because people are living longer/healthier)

What are the mandatory benefits of traditional Medicaid (pre-ACA)?

- physician services - lab and x-ray services- inpatient hospital services - outpatient hospital services- EPSDT - family planning - FQHC and rural health clinic services - nurse-midwifery - certified NP - nursing facility - home health for those in nursing facilities

What is medicare part B and what does it cover?

- physician/outpatient - voluntary (95% enrolled) - covers: physician services, outpatient services (includes medical equipment), drugs administered by physician (ex,. chemotherapy), specified preventive services, home health visits

What is medicare part D and what does it cover?

- prescription drug coverage - Created by medicare modernization act of 2003, effective 2006 - before part D there was no prescription drug coverage - voluntary (71% beneficiaries)-- penalty if you don't enroll when eligible; 90% of medicare beneficiaries have drug coverage - covers outpatient prescription drugs (formulary requirement-- list of drugs that are covered at least one in every category); variation in plan design, covered drugs, utilization management) - offered through stand alone prescription plans or medicare advantage - you can have parts A B and D together, or you can have parts C and D together

How is the ACA trying to close the donut hole/coverage gap?

- slowly increasing the amount of coverage in that coverage gap to get it to 25/75 like in the first part - Now in the coverage gap, there is coverage with brand name drugs, generic drugs, etc. - as of 2015 it was around 50/50 coverage in the coverage gap

History of Managed care

- started in 1970s, then rapid growth in 1980s/90s 1998 Medicare plus choice (Balanced budget act of 1997)--> 2003 Medicare Advantage (Medicare modernization act)

What is the future of managed care, what is the trend in enrollment?

- value based purchasing - growing-- more and more medicare advantage (part c) enrollment - medigap enrollment going down, medicare advantage enrollment going up (because medicare advantage replaced medigap)

What are some key characteristics of Medicare Part C?

- voluntary (25% enrolled) - patient enroll in private managed care plan - must be actuarially equivalent to traditional Medicare (FFS) fee for service plans* - comprehensive coverage (including Rx), - can restricts providers via networks, - additional benefits may be offered - Limits out-of-pocket spending. In 2014, average limit on out-of-pocket spending was $4,707 for HMOs, $4,927 for local PPOs, and $6,137 for regional PPOs. - financed through Parts A, B, and D: Medicare pays the insurance company a capitate rate for covering the beneficiary - Payments to MA averaged 114% of FFS in 2009

Consider how legal rights and moral/ethical judgments influence public health

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Organization of Medicaid

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Structure of Medicaid

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understand the cross-sector interactions required to advance population health

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Address the sources of disparities and consider policies to improve equity in health care and public health

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Population Health; Policies to Address Social Determinants and Disparities

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Understand how quality measures can impact health outcomes

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Three main pathways to medicare

1. Over 65 years of age and qualify for Social Security benefits (10 years or 40 quarters of earnings) - Can be your own earning record or spouse's earning record 2. Disability: must qualify for Social Security Disability Income (SSDI) and have been collecting such benefits for at least 24 months. 3. Diagnosis of end-stage renal disease (ESRD), or Lou Gehrig's disease (ALS), and receiving SSDI payments (no waiting period) Must be U.S. citizens or permanent legal resident This gets you: entitlement to Part A and eligibility to enroll in Parts B, C, and D

What are the four parts of medicare?

1. Part A: Hospitals/Inpatient Services 2. Part B: Physicians/Outpatient Services 3. Part C: Managed Care Plans 4. Part D: Prescription Drug Plans (newest addition in 2003)

____ % medicare beneficiaries make under $24k per year

50%medicare beneficiaries are usually lower income or not working anymore

Medicaid

A federal program that provides medical benefits for low-income persons.

Difference

A finding of a difference in health care use

What is value-based purchasing?

A system in which purchasers hold providers of healthcare accountable for both the costs of healthcare and its quality

Describe the Medicaid coverage gap

As enacted, the ACA Medicaid expansion would cover adults up to 138% FPL in all states, but when the mandate was revoked:- in states that chose not to expand, poor adults fall into a gap because they earn too much to qualify for Medicaid but too little for the subsidies for marketplace coverage *nearly 2/3 of adults in the coverage gap are in a family with a worker, but most work in jobs that are unlikely to offer insurance

Is brand name or generic drugs cheaper in the coverage gap and why?

Brand name because the drug manufacturers give people a discount in the gap because it is better to keep someone using their brand name even if they have to give a big discount because when the year resets and it goes back to 25/75 they are getting paid their full amount again

What are the CHIP eligibility standards? (not eligible for Medicaid, not otherwise insured)

Children: expansions up to 300% FPL; reduced matching from federal government over 300% FPL Pregnant women: new option category (SPA - State Plan Amendment) Legal immigrants: lift 5-year ban for pregnant women and children if otherwise meet Medicaid or CHIP criteria (state option) Citizenship documentation: applicable to CHIP, with option of data matching with SSA Adults: coverage eliminated and phased out

What are some key characteristics of Medicare Part D?

Created by the Medicare Modernization Act of 2003; effective 2006- voluntary (there is a penalty if you don't enroll when eligible and go without coverage) - covers outpatient prescription drugs (variation exists in plan design, covered drugs, and utilization management) - offered through stand-alone Rx plans or Medicare Advantage - financed through months premium, annual deductible, and complicated cost sharing structure ("donut hole"); subsidies available for those with incomes under 150% FPL and modest assets

EPSDT

Early and Periodic Screening, Diagnosis, and Treatment

Describe/list some policy implications of Medicaid expansion

Expansions lead to 2 different Medicaid populations and benefits within a state States can use their flexibility to structure the ABP to go beyond the EHBs Woodwork effect: initial spike in coverage followed by plateau

Financing of Medicaid

Federal medical assistance percentage - Federal share: 1-0.45 times (state per capita income/U.S. per capita income) - State share: 0.45 times (state per capita income/U.S. per capita income) - Range from 50-76% - Stimulus bill included a temporary FMAP increase - Can also qualify for enhanced matching based on unique circumstances (for example, a major disaster like a hurricane) - Administrative match set at 50% for most services - Federal government pays for 57% of Medicaid - Medicaid is 17-20% of state budgets

Part A: Funding/Financing

Financed by: - by the hospital insurance trust fund - Mandatory 2.9% payroll tax—employers and employees pay 1.45% each - Put into Hospital Insurance Trust Fund - Starting 2013, ACA provision increases taxpayers' share for higher income (more than $200,000 for individual/$250,000 for couple) from 1.45-2.35% - Deductibles for each day in patient stay • Cost sharing Hospital care after 60 days Skilled nursing facility care after 20 days

Part B: Funding/Financing

Financed by: General federal tax revenue - covers about 73% of Part B costs Monthly premium - 2018: $134/month minimum - 10% penalty for each year eligible but not enrolled, added to all future months - Higher premiums for higher incomes (over $85,000/$170,000) - Covers about 24% of Part B costs - Annual deductible ($183 in 2018) - Cost sharing

Part C: Funding/Financing

Financed through Parts A, B, and D - Essentially, Medicare pays the insurance company a capitated rate for covering the beneficiary - Payments to MA averaged 114% of FFS in 2009

Key characteristics of Old Medicaid (pre-2014)

Generally covered poor individuals who were also in one of the following covered categories: - pregnant, disabled, elderly, children, or adults in families with dependent children Usually did NOT cover: - low-income adults without disabilities - women who are not pregnant - near-poor *left ~30 million low-income individuals uninsured

Medicare Part A

Hospitals/Inpatient Services

Under ACA Expansion includes

Includes non-Medicare-eligible adults under age 65 without dependent children who are not currently eligible. Majority of uninsured adults are less than 133% FPL —69%—are adults without dependent children. 31% are parents. But, since the Supreme Court decision in 2012, states may choose not to expand.

Medicaid expansion under ACA

Increased income eligibility to national floor of 133% of FPL - included non-Medicare eligible adults under age 65 without dependent children who are not currently eligible- majority of uninsured adults less than 133% FPL *Supreme Court decision in 2012 got rid of initial ACA mandate and gave states the power to choose whether or not they wanted to expand Medicaid expansion under ACA

Under ACA Expansion is

Increased income eligibility to national floor of 133% of FPL (for most, income based on modified adjusted gross income without an assets or resource test).

What are the major cost drivers in medcare?

Increasing Rx drug prices and use: most of the most expensive drugs were under patent and could be purchased only from a single manufacturer (2010) FFS (traditional Medicare model) Multiple chronic conditions*5 most expensive health conditions: heart disease, cancer, trauma, mental disorders, pulmonary disorders

What was the purpose of the IAPB?

Independent Payment Advisory Board - Tasked with submitting proposals to reduce the rate of Medicare spending if Medicare exceeds specified targets - Created by ACA - Secretary of Health and Human Services was required to implement proposals submitted by the board unless Congress enacted an alternative proposal that achieved the same level of spending - Congress limited the board by prohibiting proposals that ration care, increase revenue, change benefits, change eligibility, or change cost-sharing - Board never implemented; repealed in 2018

Define merit-based incentive payment system (MIPS)

It is a system for value-based reimbursement under the Quality Payment Program ( QPP ) with the goal of promoting the ongoing improvement and innovation to clinical activities.

Medicare Part C

Managed Care Plans

Part A: Enrollment

Mandatory enrollment (no premiums)

Criteria for Medicaid premiums and cost-sharing

May charge premium for enrollees with incomes greater than 150% FPL May charge cost-sharing up to maximums that vary by income but not for certain services Overall, cap of 5% of household income for patient responsibility for family members on Medicaid

What are the key characteristics of post-ACA Medicaid?

Medicaid coverage (with EPSDT) for children under age 26 who were in foster care when they turned 18 Benchmark benefits for all newly eligible: - ambulatory patient services- emergency services - hospitalization - maternity and newborn care - mental health and substance use disorder services, including behavioral health treatment - Rx drugs - rehabilitative and habilitative services and devices - laboratory services - preventive and wellness services and chronic disease management - pediatric services (including oral and vision care)

what is MACRA?

Medicare Access and CHIP Reauthorization Act- prohibits medigap policies from covering Part B deductible for people who become eligible for medicare on or after January 1, 2020- so, now plan F still has $183 deductible so not entirely first dollar coverage

Medicare

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Identify the major financing and spending challenges facing Medicare

Number of Medicare Beneficiaries going up, number of workers per beneficiary going down

What are the prices of Medigap? Do they vary by state/location?

PRICES VARY WIDELY - all plan F have the same benefits but way different prices across US

Part D: Funding/Financing

Part D spending estimated to reach $88 billion in 2016, 15.5% of Medicare spending Financing - Monthly premium (varies by plan-wide variation nationwide)-In 2019, monthly premiums ranged from $10.40 to 156 - Annual deductible (varies, capped at $415 for 2019) - Sliding scale small additional premium if income more than $85,000/$170,000 (from $12.40 up to $77.40) - Complicated cost sharing structure ("doughnut hole") - Some subsidies for help with premiums and cost-sharing for those with incomes under 150% FPL with modest assets.

Population health =

Partnerships for Value

What is the role of the private sector within Medicare?

Patients enroll in private managed care plan with Part C of Medicare - Managed Care/Medicare Advantage - Must be actuarially equivalent to traditional Medicare fee-for-service - Comprehensive coverage, usually prescriptions - Can restrict providers - May offer additional benefits - Limits out-of-pocket spending -Average out-of-pocket spending in 2014: - HMO: $4,707 - Local PPOs: $4,927 - Regional PPOs: $6,137

Describe the changes in Medicaid financing under ACA expansion

Phase-in changes to FMAP: - 100% federal financing for newly eligible Medicaid for 2014-2016- 95% - FMAP for 2017- 94% - FMAP for 2018- 93% - FMAP for 2019- 90% - FMAP for 2020 and beyond

Medicare Part B

Physicians/Outpatient

Traditional Medicaid

Pre-2014: poor individuals who are also in a covered category. - Pregnant, disabled, elderly, children, or adults in families with dependent children - Approximately 59 million enrolled in 2013 • 25% of children in U.S.

Medicare Part D

Prescription Drug Plans

What was the congressional intent behind CHIP?

Reduce the number of uninsured children, build on Medicaid but not as an entitlement, and give states flexibility

Understand Social Determinants of Health

Social determinants: non-medical factors that influence health outcomes. Below is from WHO: - Income and social protection - Education - Unemployment and job insecurity - Working life conditions - Food insecurity - Housing, basic amenities and the environment - Early childhood development - Social inclusion and non-discrimination - Structural conflict - Access to affordable health services of decent quality

Describe state variations in Medicaid

State administers program and sets individual state policies for: eligibility, cost-sharing, provider reimbursement, and additional coverage "Waiver" opportunities for states to expand coverage or waive requirements

What is the purpose of Medicaid waivers?

Test out alternative programs for the benefit of the medicaid recipient

Define sustainable growth rate (SGR)

The maximum rate of growth that a company or social enterprise can sustain without having to finance growth with additional equity or debt.

True/False: If you join a Medicare Advantage Plan, you can't use and can't be sold a Medigap policy

True

True/False: Medicare reimbursement policy is moving towards value-based purchasing

True -there has been a shift from SGR to MIPS

Exceptions to Medicaid coverage

Undocumented residents are not covered States not required to cover legal residents during the first 5 years in the U.S. Federal government matches funds for pregnant women and children who are legal immigrants with less than 5 years of residency

Part C: Enrollment

Voluntary (25% enrolled)

Part B: Enrollment

Voluntary (95% enrolled)

P-periodic

checking children health at periodic, age-appropriate intervals

S-screening

doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

E- early

identifying problems early, starting at birth

Part A: Eligibility

if you are 65 you are automatically enrolled in part A - paid for by medicare hospital insurance trust fund

Medicare spending is continuing to ______________ (increase/decrease)

increase

prospective payment system

is a structure use by Medicare to pay providers where products and services (and their costs according to what Medicare is willing to pay) are defined early on and providers choose if they want to accept- - includes bundled services

D-diagnosis

performing diagnostic tests to follow up when a risk is identified

Part B covers

physician services; outpatient services, including durable medical equipment; drugs administered by a physician (e.g., chemotherapy); specified preventive services; home health visits

Children's Health Insurance Program

provides coverage for children in families with incomes too high to qualify for Medicaid. - CHIP Flexibility

Part B: Eligibility

similar to Part A

What is Medigap?

supplemental insurance coverage for out-of-pocket costs not covered by parts A and B of Medicare Medigap has 10 plan types available strictly regulated. - All plans of the same letter offer the same benefit package so that beneficiaries can compare - the C and F plans cover both the Part A and Part B deductible; "first-dollar" coverage for Medicare-covered services over 50% of people with Medigap choose Plan F - employer-sponsored supplemental coverage plans exist, however they are less common Medicaid can also be used as supplemental coverage - Medicaid helps pay for Medicare's premiums and cost sharing for 20% of Medicare beneficiaries with low incomes and modest assets (known as "dual eligibles") once you have supplemental coverage + part A + part B, you have SEAMLESS COVERAGE (you basically have no expenses when you go to the doctor)

Population Health

the health outcomes of a group of individuals, including the distribution of such outcomes within the group. - These groups are often geographic populations such as nations or communities but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. The health outcomes of such groups are of relevance to policy-makers in both the public and private sectors.

T-treatment

treating the problems found

Medicare reimbursement policy moving toward _______- based purchasing

value-based purchasing - adjustments for severity (more for complicated things) - ACA reduced reimbursement for doctors and hospitals

What are some key characteristics of Medicare Part B?

voluntary enrollment (95% are enrolled) - NOT funded by income tax; funded by general federal tax revenue instead - services covered: physician services, outpatient services (including durable medical equipment), drug administration by physician (i.e. chemotherapy), specified preventive services, and home health visits * If you don't sign up for Part B when you're eligible, you'll end up owing more money - for every year that you're eligible and don't enroll (and don't have any other coverage), there is a 10% penalty added to all future months - monthly premium ~$134 (in 2018); covers about 24% of Part B costs * premiums are higher for higher incomes - annual deductible ~$183 (in 2018) and cost sharting (usually 20%)

Describe the state of Medicare enrollment today

~60 million people with Medicare today - the Baby Boomer generation are becoming eligible at a rate of ~10,000 per day and have been for the last 10 years - Baby Boomers are healthier than their parent's generation and living longer, so a greater share of the U.S. is being enrolled in Medicare and staying on Medicare longer