Lecture 3 (medicaid) Flashcards
Who is covered under Medicare and how does reimbursement work?
Medicare Part A - Eligibility
People 65 and older
U.S. Citizenship
Permanent legal residents with at least 5 years of continuous residence
Qualify without regard to medical hx, pre existing conditions or income/asset test
People Under age 65
Permanent disabilities after receiving Social Security Disability Insurance (SSDI) payments for 24mo
People with ESRD/ALS—eligible right away!
people with end-stage renal disease (ESRD)
people with amyotrophic lateral sclerosis (ALS/Lou Gehrig’s disease)
What does Dual Eligible mean?
- “Dual-eligible” means you qualify for both Medicaid and Medicare health insurance programs.
- Dually eligible individuals are enrolled in Medicare Part A (Hospital Insurance) and/or Part B (Supplemental Medical Insurance), and are also enrolled in full-benefit Medicaid
What is Medigap? How is it purchased?
Helps pay some of the remaining health care costs
Copayments
Coinsurance
Deductibles
Medical needs when traveling internationally
Details
Monthly premiums
Covers only 1 person
Can not be canceled due to health condition
Policies sold after Jan 2006 no longer cover prescription drugs
Can Cannot be combined w/ a medicare advantage plan
What is not covered
Long-term care
Vision
Dental care
Hearing aids
Eyeglasses
Private-duty nursing
How is it paid for
You pay the private insurance company a monthly premium for your Medigap plan in addition to the monthly Part B premium you pay to Medicare. A Medigap plan only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
What is the coverage gap called within the standard benefit under the Medicare Part D program?
Gaps in coverage are called “donut holes”
Coverage gap in Medicare Part D - enrollee pays 25% (co-insurance) and plan 75% (for drug costs between $4130 and $6550)
Government not allowed to negotiate w/ pharmaceuticals for lower drug prices
High deductible & cost sharing requirements
No limit on out-of-pocket spending
There’s a temporary limit on what the drug plan will cover for drugs.
not everyone will enter the coverage gap.
The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
Who is elgible for Medicare A
- People 65 and older
- U.S. Citizenship
- Permanent legal residents with at least 5 years of continuous residence
- Qualify without regard to medical hx, pre existing conditions or income/asset test
- People Under age 65
- Permanent disabilities after receiving Social - - - Security Disability Insurance (SSDI) payments for 24mo
- People with ESRD/ALS—eligible right away!
people with end-stage renal disease (ESRD)
people with amyotrophic lateral sclerosis (ALS/Lou Gehrig’s disease)
What DME is covered under Medicare?
Covered through Medicare Part B
Required for coverage:
Doctor prescription
Durable
Used for medical reasons
Used in the home
Has expected lifetime of at least 3 years
Canes, walkers (including rollators)
Commodes
Hospital Beds
Some Wheelchairs and Power mobility
Will not cover:
Tub bench, shower chair, raised toilet seat, grab bars, high end hospital beds, limited W/C, any home modifications (no waiver programs)
What does the repeal of the OT cap for Medicare B mean
Caps for treatment have been removed
there used to be a cap on how much outpatient therapy a beneficiary can receive each year regardless of medical necessity
the bipartisan budget act of 2018 provided a permanent exceptions process that allows providers to treat patients above a set dollar amount as long as they meet certain requirements
– outpatient OT (from the slides)
- 45 minutes - $2110.00 cap (translates to evaluation + 17 sessions)
- *if reach cap, for more OT requires documentation for further skilled OT - add KX modifier
- medicare can come back later and deny payments
How is home modification covered under Medicare? Exceptions? Waivers?
medicare will not cover any home modifications
- there are no waiver programs (unlike medicaid)
Who is eligible for Medicare part B ?
Part B is voluntary, but if you are eligible for Part A you are also eligible for Part B
If enrolled in Part A, automatically enrolled in Part B, unless declined
More than 90% of people with Part A have Part B
Who is eligible for Medicare part C?
Individuals may choose to enroll in part C, if entitled to Part A and enrolled in Part B
Who is eligible for Medicare part D ?
Available to all the 55 million elderly and disabled beneficiaries through private plans - if enrolled in Part A, Part B, or both
