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48 Cards in this Set
- Front
- Back
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Medicare definition
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Public health insurance program for ppl 65 and older, ppl under 65 who are disabled, ppl with ESRD (require dialysis or transplant)
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What is an entitlement program?
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Eligible persons have a guarantee to serviced identified in the law
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How do you qualify for medicare?
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Paid into medicare through medicare taxes (payroll taxes) with enough credits = Free
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How much can you purchase medicare insurance for if you do not qualify for it?
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$450/month if you have no credits with a premium between $96 and $430 (if currently working) based on annual income whether filing jointly or individually
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What does medicare cover in general?
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Hospital stays, short stays in inpt rehab and home health care or hospice
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What does medicare cover and not cover for hospital stays?
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Covers semiprivate room, meals, general nursing, hospital services and supplies
Does not cover private duty nursing, TV, phone, private room unless medically necessary |
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Does medicare pay for inpt stay at a mental facility?
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Yes, but limited to 190 hours in a lifetime
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What does medicare cover for SNF?
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Semiprivate room, meals, skilled nursing rehab services and supplies
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What does medicare cover for home health care?
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Reasonable and necessary part-time or intermittent skilled nursing care and home health aide services; PT, OT, ST; medical social servcies, DME, medical supplies
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What does medicare cover for hospice care?
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Terminal illness; includes drugs. Medical support services: short term hospital stays and respite care
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Medicare hospital deductible and co-insurance for days:
1-60 61-90 >90 |
$1132 deductivle and no copinsurance
$283/day days 61-90 $566/day liftime reserve EACH BENEFIT PERIOD |
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What is a benefit period?
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First day of hospitilization until you have 60 days of wellness.. then a new benefit period commences. If you return to the hospital within 60 days, you do not have to pay another deductive or co-insurance. If you return 61 days later, you must pay another deductive and co-insurance even though it is in the same calendar year
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Co-insurance for SNF
0-20 days 21-100 days >100 days |
$0 first 20 days
$141.50 for days 21-100 All costs are enrolle's responsibility after day 100 EACH BENEFIT PERIOD |
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How long of a stay must you have in a SNF to be covered by medicare?
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3 day qualifying stay, rquiring a skilled bed in SNF
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How do you enroll in Part B?
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Automatically if you already get SS benefits, but you can choose to decline
If you are under 65 and disabled, you are automatically enrolled after you receive SS benefits for 24 months (ALS gets it immediatley) |
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Premiums for part B?
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$96.40 (75/25), but may be higher if income >82,000 individ or 164,000 joint
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How much more do you pay in premiums if you do not enroll for part B when eligible at 65?
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10% more in premiums each month that you did not sign up
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3 periods you can sign up for Part B
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1. Initial enrollment: 3 months before after you turn 65
2. General enrollment: Jan 1-Mar 31 each year 3. Special enrollment period: 8 months if employer or union covered insurance stops |
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How many ppl does medicaid pay all of part B for?
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7 mil
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What does part B cover in general?
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Outpt medical/surigal services, diagnostics, AMB surg center, 2nd and 3rd opinions, outpt mental health, outpt PT, OT, ST,
Home health care Outpt hospital services Blood Other services Selective preventative coverage |
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What "other services" does part B cover?
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ambulance, chiropractic (?), diabetic supplies, ER, eyeglasses (1/yr), foot exams (diabetics), Hearing/balance exams (not hearing aids), kidney dialysis med nut therapy
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Selective preventive coverage by part B?
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Bone mass measurements q 24 mo.
Blood tests for trig/chol Colorectal cancer screening (Fecal occult blood and flexible sigmoidoscopy) Diabetic services Glaucoma testing (q 12 mo) Pap test/pelvic exam (q 24 mo) Prostate cancer screen (q 12 mo) Mammograms (q 12 mo after 40 yo) Shots (flu q 12 mo) Hep B shots Pneumococcal Welcome to Medicare eam NEW (cardiac rehab, HIV screens, Pulmonary rehab) |
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Deductive and co-insurnce for Part B?
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$135 dudctible and %20 co-insurance. Medicaid will pay the 20% if they have both
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Example of shit not covered by Part B?
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Acupuncture and certain chiropractic
Custodial and long term care Dental and eye care Hearing aids Orothpedic shoes Scripts Foot care Physicals Syringes Travel |
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What does medicare beneficiary pay for home health care?
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Nothing for approved expenses and 20% of approve DME
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What does medicare beneficiaries pay for hospice care?
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Co-pay of $5 for outpt drugs and 5% of approved amt for inpt respite care
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What does beneficiary pay for for blood?
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pays first 3 pints of blood, then 80/20
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Co-insurance for outpt mental health care and lab services??
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50% mental health and 0 for lab tests
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What is "assignmnet" for part B?
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an agreement that allows a provider to collect directly from Medicare for Part B. If a provider accepts assignment, they cannot collect more than Medicare is willing to pay.
If assignment not accepted, they can charge as much as 15% OVER medicare's approved amount. Medicare will send payment to beneficiary, not provider |
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6 types of services you can choose from with Medicare Advantage (Part C)
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Medicare Managed Care
Medicare Preferred Provider Plan Medicare Private Fee for Service Medicare Specialty Plan Medical Savings Account (as rare as Andrew turning it over) Special Needs Plan (as rare as DJ splashing a jumper) |
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How does Medicare Managed Care (HMO) Part C work?
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Medicare pays a capitated rate/enrollee to private health plans
You must live within the service area of the plan and the paln has to accept you as a member (NO ESRD). Doctors, hospitals, and providers joint the network Choose a PCP who directs all health care Pay more for out of network |
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Explain how Medicare PPO (part C) works
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No referrals needed, but need pre-certification before you receive services
Can see any provider that accepts Medicare, bu tmay pay more if they are not part of the plan In 2006, PPOs limited max amt members pay |
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Explain how Medicare Private Fee-for-Service works
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Private company negotiates with proveders to decide how much it will pay and what you pay for the services that you get
May have to pay premium to join plan and there may be co-pays and coinsurance Can get extra benefits not covered under the original plan, like extra days in teh hospital |
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What is a Medicare Specialty Plan (Part C)
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For pts in long term facilities with chronic dx
Designed to provide focused health care to treat specific pt diagnoses (efficent and effective) |
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Out of pocket costs in Medicare Advantage Plan?
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Monthly premium (Medicare Adv may pay all or part of part B premium)
Co-payment and/or co-insurance Type of care you need and how often you receive it Extra benefits needed |
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When may you not need Medicare Supplemental Insurance (Medigap)?
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If you have Medicare Advantage
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What is Medicare Select?
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Medigap insurnace that costs less b/c you must use certain hospitals and certain providers to get full benefits
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What is Medicare savings program and who is it intended for?
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State funded - limited income ($1169 single, $1561 couple monthly), and limited resources (under $4000 indiv or $6000 couple)
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PACE program?
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Program for All-Inclusive Care for the Elderly - often offered under Medicaid (home health alot)
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How does Medicare decide what to pay?
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national decision after reviewing evidence related to efficacy
If not, it is the local fiscal intermediary or administrative contractor who sets the rules for payment (local coverage determination) |
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When must medicare claims be filed to be covered?
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15 moths to 27 months
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What is Medicare Part D
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Medicare covered prescription drugs - must be purchased from a participating supplier or pharmacy.. can get this with Part D or Medical Advantage Plan
Premium may be nothing or more depending on plan as well as additional deductivle toward drug costs and pentalty if enroll late |
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Part A=
Part B= Part C= |
Hospital insurance
medical insurance medicare advantage plan |
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NPI
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National Provider Identifier - Medicare requires it so they can keep track of us so we don't fuck them like they fuck us
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ABN
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Advanced Beneficiary Notice. Give to pt if doc puts a ICD-9 code on paperwork that does not meet medical necessity. Or just call doc and tell them not to be an idiot
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NEMB
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Notice of Eclusion from Medicare Benefits - to tell pt that the srevices they are about to receive will not be covered by Medicare. Req'd
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Example of when you need to attatch a -59 modifier?
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If you did a combination of group and individual therapy
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When can you charge medicare for a re-eval?
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Only when significant change has occured, requiring a change in the POC. Can not write a re-eval when d/c a pt
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