Financing and Reimbursement Flashcards
How is Medicare funded?
Federal funded
Income tax maintained
Medicare covers all of the below besides for:
Must be 65 or older
Must have disability and receive cash from SSI for 2 years and over.
Patient with cancer
Patient with ESRD (end stage renal disease)
Patient with cancer
What does Medicare part A cover?
- Pays institutions
- DRG: diagnosis related group
- Lump sum payment
- Covers employee costs, overhead and supply costs
If the hospital cost is less than the DRG with Medicare part A who keeps the difference?
The hospital.
Is home health care covered by Part A or Part B?
Part A
Which part of Medicare covers Hospice care?
Part A
Who does Medicare Part B contract with?
private insurance companies
What does Medicare Part B cover?
Private office visits
Nursing homes
Patient homes
What does Fee-for-service mean?
It is resource based relative value scale.
It gives the most flexibility in selecting a practitioner of choice.
What is the most frequent method of payment with Medicare?
Part B- Fee for service
How much does Medicare pay for fee for service?
80% after the annual deductible.
What is HMO?
health maintenance
What parts of Medicare does HMO cover?
Part A and B
What is Medicare Part C?
Medicare Choice
- paid predetermined capitation monthly fee
- offers enhanced benefits
How many Medicare beneficiaries were enrolled in Medicare Part C in 2002?
10%
How is Medicaid funded?
Jointly by federal and state gvt
Who does Medicaid provide for?
- Low income individuals
- Families with dependent children
- Aged and disabled
What is the Balanced Budget Act of 1997?
Affected Medicaid
- Greater flexibility in utilizing managed care
- funds for child health care
- PAs may be covered by the state
What are the three options with managed care?
Capitation
HMO
PPO
What type of managed care is the practitioner or hospital paid a certain amount per patient to provide medical?
Capitation
What type of managed care is when members pay a specified fee and receive all their healthcare?
HMO
What is Preferred provider organization?
PPO
- discounted fee for a group of practitioners.
