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84 Cards in this Set
- Front
- Back
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What are the 2 reasons Medicare is the most influential insurance program affecting the U.S. health care system
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1. it is the largest single payer of health care services in the US
2. It is organized and managed by the federal gov. |
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Why is it important for therapists to understand Medicare
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1. It is a powerful program and other companies model after its medical policies
2. any changes in Medicare can affect how you deliver services and documentation |
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When was Medicare enacted
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1965
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Where was medical care initially provided
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in pts homes and then as technology progressed in institutions. However people had little financial resources to pay for it.
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What began to call for improved access to med care for people with limited financial resources
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social movements
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WHat type of health care did European countries began to institiute as a result of social mvmts in the late 19th century
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Universal health care
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does the U.S have a universal health care system.
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no, but efforts have been made to have one since 1912
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WHat percentage of the elderly did not have health ins. for HOSPITAL CARE
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1 in 2 in 1960's
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HOw do the elderly differ in their financial resources and need for health care
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they have an increased need and fewer financial resources to pay for it
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WHo passed the Medicare law and which president signed the law
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Congress passed it and Johnson signed it.
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Hospital insurance for the elderly was enacted as part of a package of benefits. This pkg is sometimes referred to as
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"3 level cake"
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What does the 3 level cake consist of
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1. Part A
2. Part b 3. Part C |
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what does part a consist of
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hospital insurnance- provided coverage for inpatient hospitals stays and short term residential care for rehabilitation in other facilities
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What does Part B consist of
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supplementary medical insruance (SMI)- provided coverage for professional services (doctor's visits, PT, OT)
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What does Medicade consist of
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enacted as 1960 Kerr-Mills legilation that provided funds to the states to care for the poor
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What does Part C consist of
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includes the Managed Care options in the Medicare Program
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What does Part D consist of
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Outpatient prescription drug benefit added in 2003
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How is Medicare funded
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payroll taxes
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How does the amount pd in payroll taxes differ from the first year to the present
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in the first year .35 percent was drawn on the first $6,600 fo the workers earnings, today we pay 2.9 percent on all earnings.
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Medicare became a leader in developing what type of payment methods
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alternative
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Initally, Medicare followed the regular payment methods used by private insurers. they pd
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usual and customary charges, which were based on the rates and fees for a region.
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In modern time what payment system does medicare use?
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prospective payment system (PPS). the PPS insurers determine what it will pay for prior to the delivery of care
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WHat is a form of PPS
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DRG's
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One-half of Medicare dollars are paid out theough
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Part A
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What are the 2 programs that comprise Medicare
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Medicare and Medicare advantage (part c)
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If you have pd into the Medicare system then you get the benefits. this describes what type of program
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entitlement
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What type of insurance is described as money is trasferred from one goup to another to meed a defined social need.
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Social insurance and this is what Medicare is.
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Who establishes Medicare policies adn after established Medicare procedures are developed and implemented by
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Congressional legislation establishes them
center for medicare and medicade services develops and implements them |
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The center for Medicare and Medicade services was formally know as the
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HCFA- Health Care Financing Adminstration. and this agency is part of th eDept. of Health and Human Services.
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Claims processing and review is perfomed by
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private organizations, usually ins.co's which are called intermediaries and carriers.
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Intermediaries process and review claims for Part
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A Medicare
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carriers process and review claims for Part
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B Medicare
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WHat type of insurance is called Hospital Ins.
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Medicare Part A
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What is eligibility for Part A
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1. a record of payroll or premium contributions- for 40 quarters
2. age=65 3. marital status- spouse of eligible individ. covered 4. the presence of permanent disability- under 65 covered if they can prove permanent disablity. Takes 24 mnts to prove. Also endstage renal disease can qualify for Part A benefits |
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What are the 4 basic benefits included in Medicare Part A
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1. inpatient hospital care
2. short term skilled nursing facility care 3. home health care 4. hospice |
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HWat doe the benefits include for Part A
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room an dboard and medically necessary professional services.
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What must medically necessary services meet
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Medicare program requirements and be ordered by a physician
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Who does not have to pay a monthly premium for Part A
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vested beneficiars. But the commonly used Part A benefits are not free. they must pay a ded. and daily co-insurance.
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when do you have to pay co-insurance for Part A
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60 days after hospital care or 20 days after SNF
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What is used to caculate Part A deductible and co-insurance
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a benefit period
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How are out-of-pocket expenses usually based on for Part A
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an annual period
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Part A Medicare determines benefits for the time of ____________ to the hospital until the pt is out of the hospital or SNF for _____ days
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admission
60 |
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During the 60 day coverage, even if there is readmission how are benefits cov for co-insurace and ded under Part A
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all covered under one. ded does not restart even if readmitted within the 60 days.. after 60 days will owe an additional ded and co-insurance fees
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The SNF benefit under Medicare Part A provides _______ nursing and ______________ services
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short term
skilled rehabilitation |
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how longa are SNF benefits covered under Part A and what are the requirements of the facility
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up to 100 days. in a Medicare-certified unit per benefit period that is RELATED TO THE RECOVERY FROM AN ACUTE HOSPITAL STAY
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Under SNF benefit what does Medicare part A not cover
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1. long term institutilization - such as nursing homes
2. direct access to SNF without an acute hospital stay |
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WHa are SNF uits often called in hospitals
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subacute, swing bed, transitional care or restorative care units
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Even if the facility is located within an acute hospital they are licensed asa
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SNF unit and pd therough the SNF benefit
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How long must the pt be in acute care for Part A to cover
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3 day acute care stay during the 30 proeceeding days and they have to be certified for admissoin to the SNF by a physician
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What is not covered as activities under Part A for SNF benefit
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1. general exercise
2. routine assistance with ADL and ambulation These 2 are considered restorative therapy and can be provided by non-professionals. you can be reimburesed to develop a maintance therapy program but not pd to carry it out |
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Why is it important for therapisits to know what is considered non-skilled
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because if they charge for a non=skilled service it is considered medicare fraud
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What type of assessment must be done when admitting a person to SNF or when re-assessing them
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a Resident Assessment Insturment
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What are the Resident Assessment Instruments used under Part
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1. MDS- Minimum Data Sheet= adminsitered at admission and at routine intervals, and when a significant change in pt status occers during SNF stay
2. Resident Assessment Protocal (RAPS) 3. Utilization guidelines- provides info about how to implement the RAI. |
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Pts qualify for home health benefit based on
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home confinement and the need for skilled nursing and/or rehab services
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What is administered at addmission and at routine intervvals and when a significant change in pt status occurs during a SNF stay
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MDS minimum data set
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Where is home health therapy provided
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in pts residence(home or institution. a physician must certify the pt is confined to their home (only leaving for necessary medical tx or an occasional community outing.
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a physician must order the home health care services and they must recertivy continued need every ______ days
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62
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Pts that are enrolled in both Part A or B benefit are entitled to _________ visits of home health care if they meet the general eligibility criteria and have had a _____ day hospital stay within the prior _____days . If they exceed the _____-visit limit, they are able to continuje necessary home health care through ________--
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100 visits
3 days 14 days Part B |
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Everyone receiving home health care is evaluated using a tool called
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outcome and assessment information set (OASIS) like MDS for SNF.
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The Inpatient Rehabilitation Facility Benevit provides for __________ and ___________therapy in a _________ setting
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intensive and coordinated services in a rehabilitation setting
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Pts must receive ____ hours of therapy every day to qualify for Inpatient Rehabilitation Faciilty Benefit.
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3 hours and it is known as the " 3 hour rule"
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What rule must the facility meet to participate in Inpatient Rehabilitation Facility Benefit
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the 60% rule. Meaning at least 60% of the facility's pts must be from certain diagnosis categories.
stroke, spinal cord injury, congenital deformity amputation major multiple trauma fracture of the femur brain injury polyathritis including rheumatiod athritis neurological disorders,such as ms, motor neuron disease, polyneuropathy, musculard dystorphy and Parkinsons Burns |
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How are pts evaluated for Inpatient Rehabilitation Facility Benefit
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the inpatient rehab facility-pat assessment insturment . THe FIM is the central eval piece of the IRF-PAL
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WHat is the hospice benefit inteded for
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to treat those with a terminal illness. if this benefit is choosen the pt waives their option of active tx for their illness.
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What are the core hospice services covered by Medicar
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nursing
social services medicine counseling OT and PT are among the optional hospice benefits |
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What was the method of pyment for Medicare part A known as
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cost based reimbursement . based on reasonable and necessary charges
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The current method of payment for Part A is
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prospective pymt. cost reports are still required as an account report, but pymt is determined based on sets of predetermined criteria... Pd on an ALL-INCLUSIVE rate for a day or multiple days
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In 1983, the federal government initiated __________ for inpatient hospital stays by classifying pts into groups that could predict resource utiliztion
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prospective pymts.
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under prospective pymts, Part A, pts were classified using a system called ____________
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case mix adjustment
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Part A. How did DRG's result in pts care
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pts spent fewer days in the hospital and received fewer services thatn the previous cost-based reimbursement system
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Why did PPS have a positive impact on OT
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pts needed rehab b/c being moved out of hospital quicker. needing tx so they could go home. there was a big need for OT because pt's were being discharged and were too sick to go home
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This rule was established by congress to reduce the DRG pymt to the acute hospital for pts who are discharged more than 1 day earlier than the average for the 10 DRG's with the hightest rate of acute hospital transfers to post-acute care
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Transfer rule, put in affect to limit the abiltiy of providers to unfairly profit from an early pt discharge form the hospital to an SNF or home health care
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In original medicare these are additional days that Medicare will pay for when you are in a hospital for more than 90 days.
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Lifetime Reserve Days- you have a total of 60 reserve days during your lifetime. Medicare will pay all covered costs except for DAILY CO-INSURANCE
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What authorized the implementation of a national prospective pymt system for Medicare Part A Skilled nursing facility care that replaced cost-based reinmburesemnt
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the Balance Budget Act of 97
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SNF prospective pymt is based on the classification of persons residing in nursing homes into
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resource utilization groups.
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what is the intent of using resource utilization groups in SNF
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to pay an all-inclusive per diem pymt to providers for this care
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What is the determination of the resource utilization groups (RUGS) class for a person based on
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the results of the MDS assessment, medical diagnosis, documented therapists contact time, nursing restorative interventions, and certain behavioral observations
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Out of the 8 categories for RUGS the categories of most interes tot OT's are
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rehabilitation categories.`
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how are pts classified into a resource utilization group based on
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adl index score of the MDS, # of therapy disciplines involved in care and the amount of time spent in therapy each week
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SNF prospective pymts has given PT's and OT's incentives to move away from
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discipline specific exams and interventions. The MDS and RUGS require therapists to expand teamwork and closely count minutes of therapy intervention
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How are Inpatient Rehab Facilty Prospective pyments md
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per episode with a final pymt to the facility being adjusted for local wage conditions and certain outlier characteristics
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How are home health agency prospective pymts md
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pymts cover all home health services including theapies received during the 60 day period of care.
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What kind of equipment is excluded from theis pymt mechanism and is pd using a fee schedule
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durable= wheelchair etc
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CMS determines a standarized prospective pymt rate but teh ___________ is used to classify the pt in a HHRG which adjusts the standard pymt for individual pt needs and the geographic costs of care delivery
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OASIS
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