10/1b Intro to Medicare and Medicaid (Integrated Care and Practice)

Question 1

what percentage of americans use medicare and medicaid?

Answer 1

65% of americans!

Question 2

define medicare

Answer 2

social insurance model, requires contribution to secure a benefit
-as people got older they stopped getting health insurance because the price skyrocketed so much

Question 3

4 parts of medicare

Answer 3

1. Part A - Hospital Insurance/inpatient
2. Part B - Physician services/outpatient
3. Part C - medicare advantage plans
4. Part D - medicare prescription drug plan

(+Part A&B)

Question 4

government health insurance

Answer 4

• tax financed
• state run
• married public (government) insurance and privately operated health services

Question 5

eligibility for medicare part a

Answer 5

• 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

Question 6

how is medicare part a financed?

Answer 6

through social security system

• employers and employees each pay 1.45% of wages and salaries
• self employed people pay 2.9%

Question 7

services covered for medicare part a

Answer 7

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)

Question 8

Part B medicare eligibility

Answer 8

Persons who are eligible for Part A and who “choose” to pay the Medicare Part B premium

Question 9

how is medicare part b financed?

Answer 9

• higher premium
• deductible
• financed partially by Fed tax (personal income and other taxes) - 75% and by Part b monthly premiums - 25%

Question 10

services covered for medicare part b?

Answer 10

• 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

Question 11

PT services for medicare part b?

Answer 11

• financial limitation (CAP) for outpatient rehab services
• PT & ST share CAP because of type
• medicare therapy cap exceptions extended permanently, no longer required

Question 12

services NOT covered in medicare part b?

Answer 12

• outpatient meds
• for Rx drug plan
• eye refractions, hearing evaluations, dental services

Question 13

what consists of parts medicare a&b?

Answer 13

MACRA 2015

Medigap

Question 14

MACRA 2015

Answer 14

• 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)

Question 15

MIPS

Answer 15

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

Question 16

APM

Answer 16

Alternate Payment Method

no more increases to providers, except for if you reach certain thresholds and document certain requirements

Question 17

Medigap

Answer 17

• 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

Question 18

Medicare Part C

Answer 18

• 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

Question 19

why are more and more people joining medicare part c?

Answer 19

• premiums/costs of service are lower than traditional medicare
• BUT loses freedom of choice in cases
• requires PCP referrals for specialists
• 15% copay

Question 20

medicare part d

Answer 20

• medicare prescription plan (Bush admin 2015)
• medicare prescription drug coverage
• increase role of private health plans

Question 21

Medicaid

Answer 21

• 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

Question 22

requirements for medicaid enrollment

Answer 22

• 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

Question 23

SCHIP

Answer 23

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

Question 24

Health care reform

Answer 24

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

Question 25

quality payment programs

Answer 25

(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

Question 26

APTA healthcare reform

Answer 26

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.