CMS - Medicare and Medicaid Flashcards
Medicare eligibility - Provides hospital and medical coverage for these categories
Persons age 65 or over
Persons entitled to railroad disability benefits
Persons entitled to disability benefits for 24 months
Persons entitled to SSI due to Lou Gehrigs Disease
Persons with end state renal disease
Medicare Part A
Hospital Insurance Inpatient SNF* Home health services* Hospice Acute rehab
Medicare Part B
Medical Insurance Outpatient rehab Physician services Durable medical equipment Mental health services Ambulance
Medicare C
Medicare plan - private insurers - Advantage Plans HMO PPO PFFS POS MSA
Medicare D
Prescription drug plan
Voluntary enrollment with A or B coverage
Late enrollment = higher premium
Medicare contracts with private companies
Medigap benefits
Supplemental health insurance policy
Fills gaps within original medicare plan
Available through private insurance companies
Basically covers some or most of out of pocket expenses
Must enroll in both part A and B within 6 months of eligibility of medicare
Medicaid
Medical programs for eligible individuals and families with low income and resources
Largest source of funding for health services for people with limited incomes
When did medicaid get passed
Passed congress as title XIX of social security act in 1965
Who manages Medicaid
Centers for medicare and medicaid services (CMS)
Federal gov. monitors programs and establishes general guidelines and policies
Dept. of health and human services - individual states administermanage specific guidelines
State funded with federal match for some programs - amount vary by state
Medicaid eligibility
Pregnant women and children under 6 whose income is at or below 133% of the federal poverty level
Children 6-19 with family income up to 100% FPL
Certain children in foster care, adoption assistance programs, with disabilities
Non-elderly low income parents/caretaker relatives
Adults with disability under 65
Medicare recipients with low income
Medicaid Expansion
Started in 2014 - state choice
Coverage to non-elderly, non-disabled adults
Covers the gap of people who might be making just over but not enough for private coverage
Churning
Acute Care Hospital
Inpatient prospective payment system (IPPS) - DRG (diagnostic related group)
Medicare Part A
Covers all services provided in hospital, including PT
Inpatient Rehab Facility (IRF)
IRF PPS (IRF PAI)
Collection and reporting therapy amount - determine what medicare is paying for and is it appropriate
Need to report amount and mode of treatment
IRF - Mode of treatment - Concurrent therapy
One PT/PTA with 2 patients, performing different activities
IRF - Mode of treatment -Co treatment
More than one therapist from different disciplines to one patient at a time
IRF - Mode of treatment - Group therapy
One PT/PTA to 2-6 patients at a time performing the same activities
IRF - Mode of treatment - Individual therapy
one PT/PTA to one patient at a time
SNF
Case mix PPS - med A MDS RUGs 30 day rule 100 calendar days benefit
Home health
Med A
Homebound status - need to meet two criteria
Can also be covered by Med B
Two criteria for being “confined to home”
- Need the aid of supportive devices or assistance of another person to leave home OR leaving home is medically contraindicated
- a normal inability to leave home AND leaving home must require a considerable and taxing effort
Outpatient Care
Med B
FFS
ACO
PTPPs placed in moderate risk category and require a site visit prior to enrollment
Medicare Physician Fee schedule
How medicare decides what you will get paid
Resource Based Relative Value Scale (RBRVS) - based on difficulty of work, practice expense, and malpractice expense
Therapy Cap – Med Part B
Cap for PT and SLP combined (OT is separate)
$1940 paid per calendar year –> use KX modifier and show medical necessity
$3700 exception to therapy cap limit - manual medical review
Therapy Cap - Med Part B
extended through =
Does not apply to =
Ext. through 2017
Doesn’t apply to Medicare Advantage
Advanced Beneficiary Notice of Non-coverage (ABN)
Procedures not eligible for reimbursement
Provide before providing the items or services
Formal documentation notifying the patient that they are responsible for payment of service
Patient may request to not receive the service
Requirements with ABN
Specify frequency and/or duration of service
Explain why believe the service may not be covered
Beneficiary cannot or will not make a choice, the notice should be annotated
Collecting out of pocket
Must give the beneficiary and ABN
Submit claim with GA modifier
Medicare quality reporting programs - CMS vision for quality measurement
Align measure with national quality strategy
Triple aim = better experience of care, improve health of population, lower cost of care
Medicare quality programs ensure that
the services they pay for are high quality
Quality reporting is tied to payment adjustments
Improving post-acute care transformation act of 2014 (IMPACT)
Expands reporting requirements for post-acute providers
Quality measures for acute and post acute care
Pressure ulcers Infections Re-admissions Pain management Falls rate/risk ADLs Consumer assessment of healthycare providers and systems Use of ER with no hospitalization
Physician quality reporting system - outpatient services
System to report quality indicators
Utilizes incentive and payment adjustment program to promote participation
Successful reporting included 6 measures on 50% or more of eligible medicare patients
Physician quality reporting system - outpatient services - Two different ways to report and Future changes
Claims based reporting - 6 items
Registry based reporting - 15 items
Merit based incentive payment system (2017)
CMS functional limitation reporting applies to
All outpatient therapy services
Functional limitation reporting - categories
To be submitted with severity modifiers Mobility Changing and maintaining body positions Carrying, moving, handling objects Self care Other - other score from functional assessment tool is used, service not intended to treat a functional limitation
Functional limitation reporting - when to report
Onset of the therapy episode Minimum every 10th visit Eval or re-ecal codes being used Reporting of a functional limitation is ended and further therapy is needed for another limitation Discharge
Functional limitation reporting - modifiers
Indicate extent of severity/complexity of the functional limitation
How to determine functional limitation
use valid and reliable assessment tool and/or objective measures
