10/1b Intro to Medicare and Medicaid (Integrated Care and Practice) Flashcards
what percentage of americans use medicare and medicaid?
65% of americans!
define medicare
social insurance model, requires contribution to secure a benefit
-as people got older they stopped getting health insurance because the price skyrocketed so much
4 parts of medicare
- Part A - Hospital Insurance/inpatient
- Part B - Physician services/outpatient
- Part C - medicare advantage plans
- Part D - medicare prescription drug plan
(+Part A&B)
government health insurance
- tax financed
- state run
- married public (government) insurance and privately operated health services
eligibility for medicare part a
- 65yo & eligible for Soc. Security(persons who paid into the SS System for 10 years (40 quarters) & spouse are automatically enrolled – regardless of retirement status. Premium –free Part A.
- Persons < 65yo who are totally & permanently disabled may enroll in Part A after receiving disability benefits for 24months (under social security program)
- People with chronic renal disease (ESRD) requiring dialysis or a transplant – do not have to wait 2 years
- People who are not eligible for Social Security, can enroll in (buy in) Part A by paying a monthly premium ($422/month in 2018
how is medicare part a financed?
through social security system
- employers and employees each pay 1.45% of wages and salaries
- self employed people pay 2.9%
services covered for medicare part a
Hospital:
-first 60 days covers all costs but a deductible “per benefit period”, 61-90 OOP, 91-150 Increased OOP
-admission: requires formal admission by MD
-observation: inpatient stay determined not needed so sent to part b
SNF:
-first 20 days (all medically necessary costs covered after 3 days hospital admit)
-patient has to pay a fee after the first 20 days
Home Health/Hospice:
-100 visits per benefit period - covers 100% of costs for skilled care as defined by med regs
-hospice requires doc certifies terminal illness (6 months or less)
Part B medicare eligibility
Persons who are eligible for Part A and who “choose” to pay the Medicare Part B premium
how is medicare part b financed?
- higher premium
- deductible
- financed partially by Fed tax (personal income and other taxes) - 75% and by Part b monthly premiums - 25%
services covered for medicare part b?
- medical expenses: physician services = PT, OT, ST, DME, and diagnostic tests if termed “medically necessary”
- Medicare pays “approved” amount - 80% after deductible of $183/yr
- preventative care has no OOP costs
PT services for medicare part b?
- financial limitation (CAP) for outpatient rehab services
- PT & ST share CAP because of type
- medicare therapy cap exceptions extended permanently, no longer required
services NOT covered in medicare part b?
- outpatient meds
- for Rx drug plan
- eye refractions, hearing evaluations, dental services
what consists of parts medicare a&b?
MACRA 2015
Medigap
MACRA 2015
- medicare access & CHIP reauthorization
- SGF repealed and avoided deep cuts to PT
- Therapy cap repeal not approved
- payment reform: VALUE BASED PAYMENT = Fee for Service Reimbursement Model
- created merit based incentive payment system (MIPS)
- incentives for participation in alternate payment methods (APM)
MIPS
Merit-Based Incentive Program
- identifies meanings and objectively records patient satisfaction/experience as well as outcomes and cost
- model that medicare is using to move away from Fee for Service
APM
Alternate Payment Method
no more increases to providers, except for if you reach certain thresholds and document certain requirements
Medigap
- supplemental private insurance (purchased by former employers or beneficiaries) to pay for deductibles and coinsurance gaps in coverage (rated pricing)
- covers the 20% and the deductibles
- Medicaid budget used to cover medicare coverage gaps in nursing home and rx drugs
Medicare Part C
- Medicare Advantage plans, medicare was acquiring data and said that they would get involved in HMOs or PPOs (managed care)
- medicare contracts with private insurance companies to enroll medicare eligible persona and provide coverage for hospital, physical services (A&B) and some Rx drugs
why are more and more people joining medicare part c?
- premiums/costs of service are lower than traditional medicare
- BUT loses freedom of choice in cases
- requires PCP referrals for specialists
- 15% copay
medicare part d
- medicare prescription plan (Bush admin 2015)
- medicare prescription drug coverage
- increase role of private health plans
Medicaid
- federal program, financed in partnership with the states and administered through the states
- public assistance model - those who contribute (taxpayers) may not be eligible for benefits
- require low income people enrolled in state medicaid programs
requirements for medicaid enrollment
- based on income, financed through supplemental security program and taxes
- federal government requires states to provide a broad set of services under MA
- hospital, physician, laboratory-ray, prenatal, preventative, nursing home and health services
- MEDICAID WAIVERS - gives states more control in program beneficiaries and scope of services and required enrollment in managed care plans and healthcare exchanges under ACA
SCHIP
state children’s health insurance program
-designed to cover uninsured children in families with incomes at or below the 200% of the federal poverty level
Health care reform
Affordable Care Act (march 2010)
- Bar insurers from denying coverage because of preexisting condition or imposing lifetime limits on coverage
- allows young adults (26) to remain on parents policy
- expand medicaid to cover more people
- Cost for insurance skyrocketed and many insurance companies pulled out
quality payment programs
(QPP)
alternate payment model
bundled payment model - CJR Comprehensive joint replacement
accountable care organizations (ACO)
MIPS - merit based incentive payment system
value = quality + outcomes/cost
APTA healthcare reform
Supports reform of US healthcare delivery system – (no opinion on ACA)
Improve coverage
Improve access
Improve quality of care
Reduce unnecessary costs
Support HR 43/ S 46 – The Medicare Access to Rehabilitation Services Act.
