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CEBS GBA Exam 2 2024|Questions with Complete Solutions| Verified
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CEBS GBA Exam 2 2024|Questions withComplete Solutions| Verified
Define each part of Medicare (A,B,C,D) and the services provided under each (Mod 1.4 -
Reading) - ✔Part A = Hospital Services
Part B = Physician & Diagnostic Services
Part C = Medicare Advantage - Alternative Managed Care Option
Part D = Prescription Drugs
-Greatest choices in Part D and the Medicare Advantage Plan, which is where most of analysis is
focused on.
-C and D are paid out of pocket by recipients; A & B are funded by payroll deductions (taxes)
What is Medicare Part C and why do some people select it? (Mod 1.4) - ✔AKA
Medicare Advantage:
-Recipients have the option to enroll in a health plan with a narrowed network of hospitals and
providers that covers Part A and B but with lower out of pocket costs. These plans often include
their own prescription drug coverage. Unlike Part D, this is a voluntary choice and beneficiaries
always have the option of going back to the traditional plan. It is a choice to restrict options and
consolidate the different elements of Medicare, including cost sharing.
People select these plans because of lower costs and greater care coordination. Like Part
D, Part C has significant state variation.
What have researchers found with regard to consumer benefits and efficiency of Medicare Part
C? (Mod 1.4) - ✔45 studies - in general that Part C's HMO and PPO programs have a better
record than traditional fee for service plans in the provision of preventive services and the more
efficient use of resources. Despite high performance, a sub-group of sick beneficiaries in
traditional Medicare tends to rate their care more favorably than beneficiaries in Part C - due to
easier access to specialists. Compared to Part D (which provides a separate, uncoordinated
prescription drug benefit), choice here is less complex and could lead to greater consumer
benefits and efficiency.
,Discuss consumer choices for Physicians and Hospitals in the Medicaid Program (Mod 1.4) -
✔Federal government mandates open choice to both Phys & Hospitals; however, in the 90s,
states could obtain waivers for this provision and require Medicaid recipients to enroll in a
limited-network managed care plan (most states did).
Continued movement to Medicaid Managed Care Organizations (MMCOs) - with
comprehensive coverage paid on a risk basis.
MMCOs receive a per-member, per-person payment to provide defined set of benefits for all.
Traditionally, Medicaid pays physicians much less than private insurance or Medicare - this
limits the number of physicians who may take Medicaid, which will limit choice.
What is the difference between Medicare and Medicaid? (Mod 1.4 - Reading) - ✔Medicare:
Medicare is a federal program attached to Social Security. It is available to all U.S. citizens 65
years of age or older and it also covers people with certain disabilities. It is available regardless
of income.
Medicaid: Medicaid is a joint federal and state program that helps low-income individuals and
families pay for the costs associated with medical and long-term custodial care. The federal
government funds up to 50% of the cost of each state's Medicaid program, with more affluent
states receiving less funding than less affluent states. Because of this federal/state partnership,
there are actually 50 different Medicaid programs, one for each state.
Medicaid is also often used to fund long-term care, which is not covered by Medicare or by
most private health insurance policies. In fact, Medicaid is the nation's largest single source
of long-term care funding.
Summarize ACA with regard to:
1) Pay or Play Mandate
2) Minimum Level of Benefits (Mod 1.5) - ✔1) ERs with 50+ EE's who work at least 30
Hrs/Week on Average; gives ER choice to pay or play with respect to sponsoring EE Benefits. ER
who fail to offer qualified health benefits to EEs must pay a penalty per EE per year. EEs who
are cut loose by ERs who pay the penalty must obtain coverage elsewhere bc of the individual
mandate, or they will pay a penalty too - can purchase a plan on state/federal exchange, with
,tax subsidies available for low to middle income individuals. If EE chooses to play, must follow
all rules of ACA.
2) ER covers at least 60% of covered expenses, expressed as actuarial value of 60%. Considered
a floor because they represent the bottom/min level of benefit that can be offered to EEs with
triggering penalties.
Briefly describe the Cadillac Tax in ACA (Mod 1.5) - ✔40% non-deductible excise tax (paid by
ER) that will be levied on value of all affected health care programs a participant elects that
exceed certain dollar thresholds in 2020 and beyond (extended from 2018 date); while
minimum coverage is the floor, Cadillac tax is considered ceiling or top value of health
benefits. ER's need to manage between floor and ceiling; roughly half of large US Employers
will begin to hit the threshold in 2020 and percent is expected to rise in subsequent years.
What is a private exchange for health benefits? (Mod 1.5) - ✔Built and administered by
benefit consulting and admin firms as well as carriers/firms that specialize in private
exchange admin.
These marketplaces of health insurance/related products allow EEs to pick from a pre-selected
variety of plans offered by 1 or more insurance companies. ERs who utilize private exchanges
will remain plan sponsors - the exchange will manage communication, enrollment, pricing,
compliance, etc...Insurance carriers and PBMs pay claims, issue insurance contracts and
perform traditional duties still.
What is big attraction of private exchanges for employers? (Mod 1.5) - ✔Opportunity to
change from traditional premium contribution model (where ER pays 75-80% of premium) to a
defined contribution model. Traditional contribution model escalates the cost to the ER each
yr as costs increase. Since exchanges provide a wider array of choices to EEs, the ER can more
easily change from the traditional contribution model to a defined contribution model where a
flat amount, like a voucher, is provided to EEs who then apply that flat amount to the plan they
select. In subsequent years, ER may increase the defined contribution but at a level that is not
directly tied to cost trend. Private exchanges can operate with or without defined
contributions.
, List top strategies large employers are considering to improve health and reduce
healthcare costs (Mod 1.6) - ✔-Develop/enhance workplace culture so employees are
responsible for own health
-Develop/expand healthy lifestyle programs
-Make changes to avoid excise tax ceiling
-Adopt/expand use of financial incentives to encourage healthy activities
-Review healthcare benefits in total rewards context
-Analyze viability of private exchanges
-Expand enrollment in account based health plans (ABHPs)
-Adopt/expand use of new technologies to improve health engagement and cultivate
more informed consumers of healthcare
-Redefine company subsidy for healthcare
Discuss growing trend of low-cost and on-site health care clinics (Mod 1.6) - ✔Growing trend
of low-cost retail clinics and telemedicine options offers promise of lowering cost of on-demand
care. Ex: CVS Minute Clinics; includes flu shots, low acuity clinical visits on demand, physicals,
etc. Offers wide range of services from prevention/basic triage to management of chronic
conditions (diabetes/HD) - supported by nurse practitioners and web based technologies; could
provide cost relief but could also exacerbate the problem of fragmentation in healthcare where
coordination of care is needed.
What is single strongest drive of healthcare cost? (Mod 1.6) - ✔Misaligned incentives for
providers created by fee-for-service (FFS) reimbursement. Single most significant opportunity
to lower cost and improve health/healthcare outcomes can be found in full implementation
of value-based care.
Fee-for service (FFS) is healthcare's most traditional payment model where physicians and
healthcare providers are reimbursed by insurance companies and government agencies (third-
party payers) based on the number of services they provide, or the number of procedures
they order. Payments are unbundled and paid for separately. Big struggle is that even though
some of these may not be needed, or supported by evidence-based data, still offered.
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