Medicaire/Medicaid

Question 1

what is medicaid the main source of financing for:?

Answer 1

-safety net hospitals, health centers that serve low-income communities
-coverage and financing for nursing home and community based long term care

Question 2

what is the single largest health coverage in the US?

Answer 2

medicaid

Question 3

what is the medicaid eligibility after the healthcare reform

Answer 3

-non elderly adults with incomes at or below 138% of federal poverty level

Question 4

which plan do invididuals in observational status in a hospital use?

Answer 4

Part B

Question 5

Did all states expand Medicaid under the healthcare reform?

Answer 5

no

Question 6

Does federal law require cost sharing be identical, regardless of income

Answer 6

yes

Question 7

which services are covered under medicaire?

Answer 7

-SNF
-home health
-inpatient rehab

Question 8

Discuss Part A

Answer 8

-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

Question 9

define PPS (prospective payment system)

Answer 9

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

Question 10

what is DRGs (diagnosis related group)

Answer 10

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

Question 11

how do you qualify for a SNF?

Answer 11

-prior 3 consecutive day hospital stay
- prior hospital stay transferred to SNF within 30 days

Question 12

what is the requirements for inpatient rehab facilites (IRF)?

Answer 12

-clinically stable
-able to tolerate at least 3 hours of rehab therapy at least 5x/week

Question 13

talk about the 75% rule

Answer 13

-focus on medical necessity and functional capacity
-certain % admissions fall into 13 categories

Question 14

Talk about Part B

Answer 14

-doctors and other healthcare providers
-outpatient
-medical supplies
-preventative services
-monthly premium

Question 15

who qualifies for medicare

Answer 15

-age 65 and older
-people with disabilities
-end stage renal disease

Question 16

talk about original medicare

Answer 16

part A + B
-provided thoruhg medicare
-choice of doctors, hospitals, other providers
- covers about 80% of costs
-usually pay a monthly part B premium

Question 17

talka bout advantage plans (part C)

Answer 17

-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

Question 18

Prescription drug plans (part D)

Answer 18

-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

Question 19

medigap

Answer 19

-offered by private companies
- all gaps in