10-1b Intro to Medicare/Medicaid

Question 1

Discuss the historical development of the Medicare and Medicaid program

Answer 1

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

Question 2

Identify the 4 parts of the Medicare program

Answer 2

A: hospital insurance/inpatient
B: Physician services/outpatient
C: Medicare Advantage Plans
D: Medicare Prescription Drug Plan

Question 3

Describe the eligibility, benefits, and financing of Medicare and Medicaid

Answer 3

65 yo and

Question 4

What is medicare?

Answer 4

a social insurance model that requires contribution in order to receive benefit

marriage b/w gov. insurance and privately operated health services

Question 5

What is eligibilty for Part A medicare?

Answer 5

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

Question 6

What does medicare cover for the first 60 days?

Answer 6

Everything for first 60 days (They determine eligible service/medically necessary/require unique skills)

Question 7

What does medicare cover for the 61-90th days?

Answer 7

Additional OOP

Question 8

What does medicare cover for the 91-150th days?

Answer 8

Additional OOP

beyond 90, medicare pays for additional 60 once in a lifetime

Question 9

Does Part A cover admission or hospitalization?

Answer 9

Admission

Observation goes to Part B (outpatient)

Question 10

What does part A cover at a SNF?

Answer 10

first 20 days of medically necessary costs after 3 days of hospital admission

Question 11

What does Part A cover at a SNF for the 21st to 100 days?

Answer 11

patient becomes responsible for part of the care

Question 12

What does Part A cover at a SNF for the 21st to 100 days?

Answer 12

patient becomes responsible for part of the care

Question 13

What does Part A cover at a SNF after 100 days?

Answer 13

nothing

Question 14

What does Part A cover for HHC and hospice care?

Answer 14

100 visits (100% of costs)
100%

Question 15

What does medicare part B req. for eligibility?

Answer 15

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

Question 16

What services are offered through Medicare part b?`

Answer 16

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

Question 17

What does part B cover for PT services?

Answer 17

PT and ST share a $2010 cap

OT has 2010 cap

Question 18

What is MACRA?

Answer 18

fee-for service no longer supported; now therapeutic care billing

Question 19

What is Medigap?

Answer 19

upplemental private insurance: purchased by former employers or beneficiaries themselves to pay for deductibles and coinsurance or gaps in coverage

Question 20

What is medicare part C?

Answer 20

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%)

Question 21

What is medicare part C?

Answer 21

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%)

Question 22

What is medicaid?

Answer 22

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

Question 23

Medicaid req.

Answer 23

low income families with kids

people who receive asst. under SSI program

kids under 6yo

income below 150% fed. pov. level

Question 24

What are medicaid waivers

Answer 24

states more control in program beneficiaries and scope of services

Question 25

What’s the SCHIP?

Answer 25

covers uninsured kids in families with incomes at or below 200% of fed pov. level but above medicaid eligibility

Question 26

What does the ACA do?

Answer 26

Mandates health insurance coverage-2013 with fines & penalties on individuals & businesses that fail to comply