Intro to PT Chapter 6 Flashcards
Balanced Budget Act of 1997
Managed care programs and limits on Medicare reimbursements
risk minimization
reason for health insurance.
Patient Protection and Affordable Care Act
Set a minimum level of coverage and expanded health coverage to more Americans. Can’t deny coverage for pre-existing conditions for instance.
Health Insurance
A variety of policies that can be purchased to pay for certain health-related services and goods.
Insured
covered by a policy
subscriber
individual who purchases a policy
Covered services
benefits and benefit levels that cover services that will be reimbursed by the insurer under the policy
Durable Medical equipment
often not covered. (DME) - wheelchair, hospital bed or ventilator are examples given.
First party payment system
individual pays provider directly
second party
provider
Third party payment system
individual, employer, government pays insurance company or agency that pays provider.
health care is financed
By the individual, the employer or the government.
Major sources for health coverage under ACA for non-elderly
Employer sponsored insurance
Non- group market
ACA marketplaces
Traditional medicaid/chip
ACA medicaid expansion (where I get mine)
ACA market reforms.
Premium
cost of the insurance, out of pocket. In ACA marketplace low income people get subsidies from government to purchase insurance but often still have to pay a small premium In the non-group market it’s really expensive for the premium and not often done.
employer sponsored health insurance
health insurance purchased through their employers. Also known as group insurance.
Open enrollment
The period in the year where you can enroll in your employee health insurance plan. Once a plan is chosen you’re usually locked in for a year.
Co-pays and deductables
commitments the subscriber must meet directly out of pocket. Deductible is often a cash amount and may vary based on type of service. After the deductible is met the insurer will be responsible for more or all of the payments for that service.
Copayments
are a flat dollar amount the subscriber has to pay for a specific health service.
Coinsurence
a percentage cost that is covered by insurance and percentage required to be paid by subscriber. Often 80/20. Often kicks in after the deductible is met.
CHIP
Children Health Insurance Program
(like Medicaid but for children)
Access
The ability to receive health care services when needed.
Medicaid expansion
available for people up to 138% of poverty. (Some states didn’t expand Medicaid.)
ACA Market place subsidies
Available on an income basis up to 400% of level of poverty.
(When I was taking care of my father, he paid me the exact level of poverty each year which provided me with 100% subsidy on the marketplace. 400% of poverty is probably much less subsidy.)
Centers for Medicare and Medicaid Services (CMS)
Under the department of Health and Human Services. Administers Medicare (for the elderly and disabled.) and works with states to administer Medicaid. Largest purchaser of health insurance in the United States.
Medicare
enacted in 1965. For people 65 and over, renal failure, disabled and entitled to social security benefits. 60 million beneficiaries.
Entitlement program
Americans age 65 and older who have contributed to Medicare through taxes are entitled to it.
Beneficiary
Individual entitled to the Medicare program. Like a subscriber.
Medicare Part A
Hospital insurance. Inpatient hospital care, skilled nursing facility, some home health, and hospice. Paid for by 1.45% tax on wages or taxable gross.
Medicare Part B
Supplementary Medical Insurance (SMI) - Funded by beneficiary premium payments matched by the government. Most people will pay $135 a month with a deductible of 185 per year. 2.5 million will have their part b increase no more than their increase in social security. High income people pay more.
pays for physician services, outpatient and some home health,. Medical equipment and supplies. Physical therapy.
Medicare Part D
Medicare Prescription Drug plan. Federal subsidy for prescription drug insurance.
Medicare Prescription Drug, Improvement, and Modernization act of 2003
also referred to Medicare Modernization Act or MMA. Created Medicare Part D and went into effect 2006
low income seniors
7.2 million seniors who have Medicare also have Medicaid. (skilled care necessity after they take all your money.)
Medicare Advantage
Private insurance paid for with Medicare subsidy. Required to cover everything Medicare would have covered but not necessarily to the same degree. Must pay a premium often bigger than the Part B premium and often have co-pays and may have coinsurance. (Many seniors now consider it a scam.) The book says it offers seniors more choice as some plans cover things Medicare does not but may lack coverage in other areas.
Choose A and B or Advantage (C)
Medicaid
Low income adult insurance. Funded by state and federal governments. 72 million people. 62.5% by federal government 37.5% by states.
Medicaid eligability
In states that didn’t expand under ACA it required you to be at 50% of poverty level. In 2024 that’s about $7500 in income or less to qualify. In states that expanded it goes to 138% of poverty level. (15,060*1.38 = $20,782)
low income people on disability
4.8 million low income people on disability and medicare also have medicaid
dual eligible people percent of Medicare spending
32%
Children’s Health Insurance Program Reauthorization
Act
feb 4 2009. Obama. Reauthorized CHIP which covers 7 million children.
Balanced Budget act of 1997
Clinton - Balanced the federal budget but cut entitlement spending. 115 billion for medicare and 13.6 billion for medicaid.
Cuts from BBA for rehabilitation providers
$1.7 million.
Health care costs trend
Go up much faster in USA than other developed nations. will reach 6 trillion by 2027
Fraud
defined as an intentional deception or misrepresentation made by a practitioner to gain a benfit to which they are not entitled. (billing for services not furnished.)
