L2 Insurance and Aging Flashcards
Medicaid
state allocated
low income
custodial care or health care
Medicare
federally funded
age/condition
health care
Medicare Overview
-federal health insurance program
-funded by payroll withholdings and premiums
-recipients are over 65, have ESRD, a disability, or ALS
-has four parts
Medicare Part A
-Covers hospital/IRF, skilled nursing, home health, and hospice
-very specific criteria for coverage
-short-term treatment/coverage
-usually no premiums, but deductibles/copays
-does not cover caregiver costs
-uses benefit periods, not benefit calendars
2024 Deductible for Medicare Part A
$1632 per benefit period
How many days can you spend at the hospital without a cost with medicare A?
60
How many days can you spend at the SNF without a cost with medicare A?
20
What two services under medicare part A are free no matter the amount of days?
Home health
Hospice
Hospital Coverage Criteria for Medicare Part A
-Admitted to hospital
-Doctor’s order/note for necessity
-hospital accepts medicare
covered until inpatient level of care no longer needed, and covered as a flat rate
Inpatient Rehab Facility Coverage Medicare Part A
-doctor indicates necessity
-patient can do 3 hours of rehab per day
-PT is helpful because it helps with successful discharge
Skilled Nursing Facility Criteria for Medicare Part A
-hospital admission of 3 midnights
-doctor’s note of necessity
-has to have services within 30 days of hospital discharge
-has to have a need for skilled services during hospital stay
-max stay is 100 days
Benefit period for SNF
episode of care beginning with hospital admission and ending 60 days following last covered day of skilled services.H
Home Health Criteria for Medicare A
-must be homebound
-can be to prevent decline or improve function
-skilled services are required on part-time basis
Medicare Part A Section GG
standardized assessment that evaluates self care and mobility
Medicare Part A Hospice Criteria
-patient is terminally ill
-6 mo or less to live
-focus on comfort rather than curing
-medicare covers everything that is needed for terminal condition, additional insurance for non-terminal conditions
Medicare Part B
Optional insurance that can be purchased by >65 yo or disabled
has premiums ($175 per month) and Deductible ($240 per year)
covers outpatient services, medically necessary services, and preventative services
PT in Medicare B
has a limit of $2330, and then must be proved to be a medical necessity to continue. combined with SP
after $2330, you have to add the KX modifier threshold to signifiy that ongoing treatment is a medical necessity
billed as eight minute rule (each treatment has to be at least 8 minutes)
Professional Claims
reduction for that therapist’s services
Institutional Claims
reduction for all services
Medicare Part C
-private insurance that is medicare approved that cover the services that medicare does
-offer medication, dental, and vision benefits
-could be more economical than medicare
What percentage of medicare advantage enrollees have united healthcare or humana?
47%
More people have…
medicare advantage than traditional medicare
Medicare Advantage
special needs plans that provide benefits/services that are tailored to best meet the beneficiaries
Types of Medicare Advantage
- D-SNP Dual Eligible = medicare and medicaid
- C-SNP Chronic Condition
- I-SNP institutional: long term care, assisted living
Pros of Medicare Advantage
-limited deductibles
-may waive 3 day hospital stay
-coverage of extra services
-clear provider network
-motivation for prevention services
-may have alt payment models
Cons of Medicare Advantage
-prior authorization
-limited provider network
-variability in plan/cost/coverage
-case-managed care
-motivation to limit services
Therapy reimbursement for medicare advantage
Part A = medicare PDPM or PDGM, flat daily rate, or tiered daily rate.
Part B = physician fee schedule, flat unit rate, per visit rate
Medicare payments are based on
CPT code used
relative value units billed
Rate equation
Total relative valuable units X conversion factor
What year does medicare hope taht there is 100% registration?
2030
Decreases in pulmonary system with aging
- vital capacity
- tidal volume
- alveolar surface area
- alveolar vascularity
- strength of respiratory musculature
- lung expansion
Increases in pulmonary system with aging
- residual volume
- respiratory rate
- functional residual capacity
- chest wall system
Normal changes in genitourinary system with aging
- decreased urethral coaptation (elasticity)
- decreased urethral closing pressure
- atrophy of pelvic floor musculature
- diminished bladder sensation
- weakening of detrusor muscle
in women (GU system)
weakened support for bladder neck leading to stress incontinence with aging
in men (GU system)
benign prostatic hyperplasia becomes common with aging
Osteoporosis
loss of bone mineral density as measured by DEXA/DXA
T scores for osteoporosis
≥ -1.0 = normal
-1 - -2.5 = low bone mass or osteopenia
<-2.5 = osteoporosis
Most common osteoporosis fractures
hip
spine
distal radius fracture
How many people had osteoporosis?
10 million over the age of 50
greater in women
RF for Osteoporosis
- age
- family history
- low body weight
- caucasian and asian
- menopause
- history of fractures
- diet
- gluccocorticoids
Fragility Fractures
- fractures resulting from a low impact force
- any fall that occurs from a standing height
- commonly seen with osteoporosis
Vertebral Fractures
- most common type of osteoporotic fracture
- compression fractures involve anterior aspect of vertebra
- causes: ADLs involving bending and twisting
- usually asymptomatic, nearly 1/3 are undiagnosed
Treatment for vertebral fracture
- control pain
- activity modification
- resume normal activities as soon as possible to load the bone
Hip Fractures
- common in white females 85+
- caused by falling, cognitive impairment, polypharmacy
- use AD/AE to reduce
Comorbidities for hip fractures
CHF
kidney disease
cognitive changes
frailty
arthritis
LBP
Types of hip fractures
intracapsular
extracapsular
Intracapsular hip fx
femoral neck and femoral head
can accompany avascular necrosis
treated with arthroplasty or internal fixation
Extracapsular hip fractures
- Higher rates of displacement, and causes decreased gait speed
- accompanied with edema, pain
- fixed with internal fixation
Prognosis for hip fx
- 12 months for LE function
- 4 months for UE ADLs
- 1 year mortality is 12-37%
- possible chronic pain and increased fear of falling
- some will fail to reach premorbid activity or functional level, leaving them immobile
- 20% will become immobile
Types of urinary incontinence
- stress
- urge
- mixed
- functional
- insensible
- postural
- Chronic retention
- Nocturia
- Over active bladder
- Incomplete emptying/retenion
Stress UI
loss of urine with movement or other physical exertion like sneezing, coughing, standing up, lifting
Urge UI
loss or urine associated with urgency to urinate
Mixed UI
loss of urine due to urgency and with movement/physical exertion
Functional UI
physical disability or cognitive impairment leading to the inability to urinate in an appropriate place
i.e placing walker too far away
Insensible UI
loss of urine and the individual is unaware of how it occurred
i.e dementia
Postural UI
involuntary loss of urine resulting from change in body position
Chronic Retention UI
involuntary loss of urine resulting from incomplete emptying of the bladder
Nocturia UI
having sleep disturbed more than 1-2 times per night because of the need to urinate
Over-active bladder
a condition in which there is an urgency to urinate that is often accompanied by frequency and nocturia. no underlying pathology
Incomplete Emptying UI
bladder doe not feel empty after micturation
UTI prevalence
- 20% community dwelling older adults
- greater than 50% of institutionalized older adults
- more common in women
RF for UTI
- shorter urethra in women
- poor toileting hygiene
- bladder retention
- indwelling catheter
Common UTI S/S
dysuria
frequency
urgency
suprapubic pain
hematuria
Common older adults s/s for UTI
confusion
delirium
falls
change in cognitive status
what are IRFs paid under?
prospective payment systems
rate is determined by outcome measures, like IRF-PAI
