Medicaire/Medicaid Flashcards
what is medicaid the main source of financing for:?
-safety net hospitals, health centers that serve low-income communities
-coverage and financing for nursing home and community based long term care
what is the single largest health coverage in the US?
medicaid
what is the medicaid eligibility after the healthcare reform
-non elderly adults with incomes at or below 138% of federal poverty level
which plan do invididuals in observational status in a hospital use?
Part B
Did all states expand Medicaid under the healthcare reform?
no
Does federal law require cost sharing be identical, regardless of income
yes
which services are covered under medicaire?
-SNF
-home health
-inpatient rehab
Discuss Part A
-no premiums unless pt or spouse has not worked 40 or more quarters in their life
-primary payer for: acute care, SNF, home health, inaptient rehab, hospice
- no further coverage after lifetime days exhausted
-no out of pocket max
acute care, IRF, long term care
define PPS (prospective payment system)
Part A does NOT use fee for service
-PPS is a replacement for FFS
-payment of a set amount to the provider for each admission episode
-used in multiple settings but called diff things
what is DRGs (diagnosis related group)
a type of PPS
-classifies acute hospital cases into one of 500 groups
-ICD diagnoses, age, sex etc used to categorize
-incentive= quick d/c
how do you qualify for a SNF?
-prior 3 consecutive day hospital stay
- prior hospital stay transferred to SNF within 30 days
what is the requirements for inpatient rehab facilites (IRF)?
-clinically stable
-able to tolerate at least 3 hours of rehab therapy at least 5x/week
talk about the 75% rule
-focus on medical necessity and functional capacity
-certain % admissions fall into 13 categories
Talk about Part B
-doctors and other healthcare providers
-outpatient
-medical supplies
-preventative services
-monthly premium
who qualifies for medicare
-age 65 and older
-people with disabilities
-end stage renal disease
talk about original medicare
part A + B
-provided thoruhg medicare
-choice of doctors, hospitals, other providers
- covers about 80% of costs
-usually pay a monthly part B premium
talka bout advantage plans (part C)
-private insurance companies
- use network providers
-usually include prescriptiion drug coverage (part D)
- if you use outside provider, you may have to pay more of all the cost
-include all benefits and services under part A +B
- copay or coinsurance
-preminum in addition to part B premium
-extra: vision/dental for extra cost
in order to enroll, must be eligible for medicare but do not receive their medicare throuhg OG medicaire
- can have hospital and med benefits administered thoruhg private company
Prescription drug plans (part D)
-if you dont join when first eligible, may pay late enrollment penalty
- add drug coverage
- run by private insurance companies
- monthly premium (usually) in addition to part B premium
-if your medicare advantage plan offers drug coverage, you may have to get it through the plan
medigap
-offered by private companies
- all gaps in
