Answer:

U.S. citizens who paid Medicare taxes for at least 10 years and have reached age 65. Some people younger than 65 can get Medicare coverage if they have End Stage Renal (Kidney) Disease (or ESRD) or if they have been on Social Security disability for 2 years.

Answer:

As we learned in lesson 1, Medicaid members generally do not pay for their coverage, or they pay very little. Medicaid eligibility is based on income (available to those who meet certain poverty criteria) and disability. Pregnant women can generally have higher incomes and still be eligible. Each state gets to set its own income requirement levels beyond the federal minimum requirements.

Answer:

Yes. More than 9M people are covered under both Medicare and Medicaid. They are referred to as “dual eligibles” or “Medicare-Medicaid” enrollees. Dual eligibles are generally sicker and have more chronic conditions compared to non-dual eligibles in the Medicare or Medicaid program. The dual eligibles account for a significant portion of the costs in each program. Services for dual eligibles cost more than $319B in 2011 alone.

Answer:

The services covered by Medicare and Medicaid are similar, with a few important exceptions. Medicare covers most healthcare services using different “parts”: Medicare Part A covers inpatient hospital services, skilled nursing facility services, home health and hospice care. Most members do not pay a premium for this coverage (it was paid for during their working years via taxes taken out of their paycheck).

Medicare Part B covers outpatient services like doctors visits, durable medical equipment, lab tests and x-rays. Members pay a monthly premium for this coverage. Medicare Part C is not a different benefit category, but instead is used to let private insurance companies (like BlueCross or Aetna) provide benefits to Medicare members. When members opt for Part C coverage (as opposed to original Medicare), they enroll in a Medicare Advantage plan. Medicare Part D covers prescription drugs, and members have to pay an additional monthly premium for it.

MEDICAID covers all these same services, but also covers additional services like long term nursing home stays.

While both programs have a similar benefit package, the limits and coverage restrictions can be very different. In general, Medicaid allows for more service utilization than Medicare by placing less restrictions on services like the number of home health visits or therapy sessions allowed. Since each state gets to make decisions about their Medicaid program, there can be many differences in covered services across states.

However, in order to receive the federal matching funds for Medicaid, all states have to cover services in the Mandatory Benefits category. Things in included in mandatory benefits are things like inpatient hospital, outpatient hospital, home health, early periodic screening, diagnostic and treatment services (EPSDT) and many other types of mandatory benefits. Optional Medicaid benefits categories include prescription drugs, physical therapy, dental, podiatry, eye glasses, hospice and many other types of service.

Answer:

Medicare is required to follow an evidence-based process to determine coverage of services, items and devices for Medicare members. In general, the coverage decision making process must approve what is “reasonable and necessary.” This process is referred to the National Coverage Determination (NCD) process, and is laid out in detail in the Federal Register. There are also Local Coverage Decisions (LCDs) in which a Medicare carrier might cover (or non-cover) a service that has not been considered for coverage nationwide.

MEDICAID coverage is not required to follow a standardized process. Each state can make specific coverage decisions within the broader Mandatory Benefits categories using (or not using) a coverage decision process of their choosing. Most states do not publish the process or standards they use to make coverage decisions for Medicaid benefits. As of the time of this writing (2016), Oregon was that had a clearly defined coverage decision process for its Medicaid program. Other states (such as New York) have a varying degree of definitions for considering whether a particular service should be covered.

Finally, in states with Medicaid managed care, many specific coverage decisions are made by the insurance carrier operating the Medicaid plan. Such decisions follow the standards in use by that plan, which may or may not be published.

Answer:

Medicare spending in 2016 was estimated to be about $591B, with about 55M total members enrolled. Medicare spending is currently predicted to be $1.5T annually by 2022. Medicaid spending in 2015 was estimated to be about $496B, with about 73M total beneficiaries enrolled. Medicaid spending is currently predicted to be $622B in 2022. Current spending combined for the 2 programs is roughly $1T; combined spending is projected to be about $2.1T in 2022. Current combined enrollment is about 128M people.

Medicare and Medicaid spending has some similarities, but several differences. The main similarity is that more than ¼ of all spending in each program goes through health plans. After that, differences emerge. Medicare spending is focused on hospital care and drugs, while Medicaid spending is focused on long term care (in and out of nursing homes). See more information on the spending breakouts for each below:

Medicare

• payments to health plans - 26%
• hospital services - 23%
• doctors - 12%
• rx - 11%

Medicaid

• payments to health plans- 31%
• hospital services - 14%
• nursing home services - 12%
• home health services - 13%

Answer:

The Medicare carriers are health plans that CMS pays to deliver Medicare benefits to members using the health plans’ contracts with providers, claims payment technology and other capabilities. Medicare has used carriers since the beginning of the  program (1966), although they used to be called Part A Fiscal Intermediaries (FI) and Part B carriers.  Each carriers is given a region (often multi-state) in which it processes claims for Medicare members. CMS calls the carriers Medicare Administrative Contractors (MACs). There are currently 12 MACs that deliver Medicare Parts A and B, and an additional 4 MACs that focus on durable medical equipment.

Answer:

In general, Medicare regulations related to operations and payment schedules are managed using either specific acts of Congress (such as the Deficit Reduction Act, the Affordable Care Act, or the Medicare Modernization Act), the activities of Congressional committees (such as the Medicare Payment Advisory Committee, or MACPAC), or updates to the Code of Federal Regulations (CFR, also discussed in lesson 1). Medicare coverage decisions may be made at the local (carrier / regional) or national level. CMS often summarizes upcoming or proposed changes to Medicare regulations in the Quarterly Provider Updates.

For Medicaid, updates to regulations are most often made at the state level via the provider manuals. The provider manuals are typically updated quarterly and are the policy in force at the times noted in the manuals. There may also be changes to state laws, rules and regulations related to Medicaid, but these are rare. National-level changes to the Medicaid program also occur in CFR. Medicaid regulations are also updated via national legislation (such as the Balanced Budget Act, the CHIP Re-authorization Act and the Affordable Care Act), but this approach is much less often than the changes made regularly at the state level.

Answer:

Medicare Part D covers prescription drugs for both Medicare and dual-eligible Medicaid members. The Part D benefit was created in 2003, and has played a significant role in paying for drugs in both Medicare and Medicaid.