10-1b Intro to Medicare/Medicaid Flashcards
Discuss the historical development of the Medicare and Medicaid program
Before Medicare, less than 15% of elderly had health insurance (couldn’t afford private insurance outside the workplace)
Opportunity to marry the public and private sector
Govt. finances these, but they’re administered through private insurance
Identify the 4 parts of the Medicare program
A: hospital insurance/inpatient
B: Physician services/outpatient
C: Medicare Advantage Plans
D: Medicare Prescription Drug Plan
Describe the eligibility, benefits, and financing of Medicare and Medicaid
65 yo and
What is medicare?
a social insurance model that requires contribution in order to receive benefit
marriage b/w gov. insurance and privately operated health services
What is eligibilty for Part A medicare?
65 yo and eligible for Social Security (pay into it for 10 years)
pay premium
less than 65 with total and permanent disability can enroll after 24 mo. of disability
ESRD don’t have to wait
or you can pay a lot as a monthly premium
What does medicare cover for the first 60 days?
Everything for first 60 days (They determine eligible service/medically necessary/require unique skills)
What does medicare cover for the 61-90th days?
Additional OOP
What does medicare cover for the 91-150th days?
Additional OOP
beyond 90, medicare pays for additional 60 once in a lifetime
Does Part A cover admission or hospitalization?
Admission
Observation goes to Part B (outpatient)
What does part A cover at a SNF?
first 20 days of medically necessary costs after 3 days of hospital admission
What does Part A cover at a SNF for the 21st to 100 days?
patient becomes responsible for part of the care
What does Part A cover at a SNF for the 21st to 100 days?
patient becomes responsible for part of the care
What does Part A cover at a SNF after 100 days?
nothing
What does Part A cover for HHC and hospice care?
100 visits (100% of costs) 100%
What does medicare part B req. for eligibility?
eligible for Part A and who “choose” to pay the Medicare Part B premium of $134/month (premium covers 25% of financing and the rest taxes)
higher premium for greater income
What services are offered through Medicare part b?`
Medically necessary services/determine worth
Medicare pays 80% of their approved amount to get reimbursed the 80%, go to patient for the 20%
covers preventive care w/out OOP
Doesn’t cover medications, Rx. Drug plan, Eye refractions, hearing evaluations, dental services
What does part B cover for PT services?
PT and ST share a $2010 cap
OT has 2010 cap
What is MACRA?
fee-for service no longer supported; now therapeutic care billing
What is Medigap?
upplemental private insurance: purchased by former employers or beneficiaries themselves to pay for deductibles and coinsurance or gaps in coverage
What is medicare part C?
Medicare Advantage Plans
Medicare contracts with private insurance companies to enroll Medicare eligible persons and provide coverage for hospital, physician services (Part A& B) and some Rx drugs
low premiums
can involve high co-pays (15%)
What is medicare part C?
Medicare Advantage Plans
Medicare contracts with private insurance companies to enroll Medicare eligible persons and provide coverage for hospital, physician services (Part A& B) and some Rx drugs
low premiums
can involve high co-pays (15%)
What is medicaid?
a public assistance model where benefits are det. by federal programs that are financed in partner with the states
financed through supplemental security program and taxes
Medicaid req.
low income families with kids
people who receive asst. under SSI program
kids under 6yo
income below 150% fed. pov. level
What are medicaid waivers
states more control in program beneficiaries and scope of services
What’s the SCHIP?
covers uninsured kids in families with incomes at or below 200% of fed pov. level but above medicaid eligibility
What does the ACA do?
Mandates health insurance coverage-2013 with fines & penalties on individuals & businesses that fail to comply
