MANAGED CARE May 1998. ©1998 Stezzi Communications

Gaps in Medicare coverage can mean significant out-of-pocket expense for low-income elderly and disabled recipients. Many such Medicare recipients are eligible for Medicaid assistance for Part B premiums and services not covered by Medicare, such as prescription drug coverage. But a report by the Kaiser Commission on the Future of Medicaid suggests that bureaucracy and poor promotion keep few "dual eligibles" from claiming their full share of benefits. The commission says the emerging role for managed care in Medicare and Medicaid offers the promise of coordinated care for dual eligibles.

Medicaid benefits available to Medicare recipients:

  • Full Medicaid benefits are available to Medicare recipients who are entitled to Supplemental Security Income or have incurred large health expenses.
  • Qualified Medicare beneficiaries (QMBs) have incomes below 100 percent of poverty and limited assets. Medicaid pays Medicare's premiums and deductibles for this group, but only 63 percent of 367,000 QMBs received Medicaid benefits in 1996.
  • Specified low-income Medicare beneficiaries (SLMBs) have incomes 100—120 percent of poverty and limited assets. Medicaid pays Medicare Part B premiums for this group, but only 10 percent of 195,000 SLMBs received Medicaid benefits in 1996.

The Balanced Budget Act of 1997 provides states with block grants to help Medicare recipients pay Part B premiums. Beneficiaries with incomes between 120 and 135 percent of poverty are entitled to full payment of Part B premiums, while those whose incomes are between 135 and 175 percent are eligible for coverage for a portion of benefits.


Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.