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HCD > Medicare > Flashcards

Medicare Flashcards

1
Q

What does Medicare not cover?

A

Dental, hearing aids, eyeglasses, custodial care

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2
Q

High cost-sharing requirements

A

Deductibles for Parts A, B, D
Coinsurance, copayments
Part D coverage gap

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3
Q

Medicare Etc

A

No limit on out of pocket spending

Pays about half of beneficiaries total health and long term care spending

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4
Q

Medicare Part A

A

Hospital Insurance: inpatient care (acute and SNF), home health, inpatient rehab, hospice

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5
Q

Medicare Part B

A

Medical Insurance/Outpatient

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6
Q

Medicare Part C/ Advantage

A

Try to add market forces to the program

Run by private companies

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7
Q

Medicare Part D

A

Drug benefit
Replaced no drug coverage in the MMA of 2003
Written directly by the pharmaceutical companies

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8
Q

A and B

A

Part A uses PPS
Provider charges Medicare for services it has provided to medicare beneficiary
Medicare pays them for service based on a fee schedule through a 3rd party administrator called a MAC

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9
Q

What is a Diagnosis Related Grouping (DRG)?

A

Get a set amount for an illness. If the pt is D/C’d then returns later, they get another set of money to treat the pt so theyre incentive to spend more time with them

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10
Q

Health Reform (Fee for Service)

A

Encourages more services
More expensive services
Rewards specialists, not PCP
Does not encourage prevention

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11
Q

Part A Acute Care Hospital Benefit

A

No premium unless worked more than 40 quarters
Hospital deductible (1216)then paid fully x 60 days of illness
60-90: 304/day
90-150 days: 608/day
No coverage after 150 days
No out of pocket maximum

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12
Q

Prospective Payment System (PPS)

A

Funding model replaces FFS
Fixed amount payment to provider/institution for each admission
Used in multiple settings
Started in acute care (DRGs)
Home health and SNF PPS began with BBA of 1997, put in place in 1999

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13
Q

Diagnosis Related Group (DRG)

A 
A type of PPS
Classifies hospital cases in 500 groups
Incentive for quick d/c
Minimization of costly care
Minimization of staffing levels
Shorter hospital stays, more post-acute care
Sicker and more disabled upon discharge
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14
Q

SNFs

A

Medicare pays for temporary housing

custodial care is Part B

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15
Q

Part A SNF coverage

A

Day 1-20: no coinsurance/cost-sharing
20-100 days: 152/day
After 100 days no coverage

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16
Q

Qualify for SNF

A

Inpatient who needs skilled nursing care or other rehab services on a daily basis
Prior hospital stay within 30 days
SNF PPS=RUG Levels=MDS

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17
Q

SNF PPS

A

Facilities are paid a lump per diem rate based on RUG levels (case mix)
Covers medications, supplies, nursing, rehab, etc

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18
Q

RUG Levels

A

Resource Utilization Group/Case Mix
AKA MDS 3.0 or RUG IV
66 RUG Groups

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19
Q

MDS 3.0 Minimum Data Set

A

Info on nursing needs, ADL impairments, cognitive status, behavioral problems, medical diagnoses
Determines which case mix/RUG level which determines payment

20
Q

Ultra high RUG Group

A

Use most resources, facility gets paid more to have them since more expensive, needs more minutes of therapy. Can be risky only taking ultra high
Classify pts as high as possible

21
Q

Home Health Care

A 
Homebound
Under care of physician
Requires skilled care of nursing, PT, or speech
Prior 3 day hospitalization
OASIS documentation form
22
Q

Inpatient Rehab Facilities Requirements

A

Clincally stable
Able to tolerate at least 3 hours of rehab (combined PT, OT, speech) at least 5x/wk
75% rule

23
Q

Medicare and IRFs

A

Medicare pays IRFs a higher rate then hospitals/SNFs due to specialized rehab

24
Q

75% Rule

A

Focus on medical necessity and functional capability

75% must be in one of 13 categories. If 75% of ppl in IRF meet the category, then new pt can have any problem

25
Q

Implementation/freeze

A

2010 ruled a permanent freeze at 60%, so a minimum of 60% of admissions must meet critieria, not 75%
Caused some IRFs to close, SNFs had increased pt use

26
Q

Part A Finance

A

1.45% payroll on workers
Matched by employer
Self-employed paid full amt
Must work 10 years to qualify

27
Q

Part B: Supplemental Medical Insurance

A 
Physician services
Outpatient care including outpatient PT
Ambulance services
Preventative services
Lab/diagnostic testing
28
Q

Part B Coverage

A

Premium 104 if make under 85000/yr
Deductible 147/yr
Coinsurance of 20% Medicare approved amt

29
Q

GA Modifier

A

ABN (advanced beneficiary notice) in place

Means pt is aware that they will have to pay if the service is not covered by Medicare

30
Q

59 Modifier

A

CCI (Corrective Coding Initative) Edit Exception

31
Q

Part B Therapy Cap

A

PT and SLP combined $1920

32
Q

Automatic Exception

A

Manual exception no longer exists. KX modifier used. Need documentation
Significant ability to provide services above the cap, must meet requirements
Example: if pt uses all 1920 for one diagnosis then gets another diagnosis they get a new 1920, must use a KX modifier in exemption

33
Q

Multiple Procedure Payment Reduction (MPPR)

A

Payment reduction when multiple CPT codes billed on same date of service
Part B
Resulted in cuts to PT and others since its the number of codes, not types

34
Q

ABN (Advanced Beneficiary Notice)

A

Notice saying Medicare may not pay for certain services and that the Beneficiary may need to pay if they want the service

35
Q

CCI Edits (Correct Coding Initiative)

A

Ensures most comprehensive groups of codes are billed rather than component parts
Checks for mutually exclusive code pairs
Bill for what Medicare will most likely bill for if there is overlap

36
Q

CCI 59 Modifier

A

Certain codes are prohibited from being billed on the same day. Add 59 modifier to indicate that services were performed during different time intervals. Don’t bill a modifier on every claim

37
Q

Medicare Direct Access

A

Don’t need a referral, but need a physician to sign a Plan of Care

38
Q

Part B Funding

A

Premium withheld from Social Security check
Premiums cover 25% of plan
75% comes from tax revenues

39
Q

Supplemental Coverage (Part C)

A

88% beneficiaries get supplemental coverage in addition to Parts A and B

40
Q

Types of Supplemental Coverage

A

Medigap Plan
Medicaid supplement
Employer Sponsored
Medicare Advantage/Part C

41
Q

Part C

A

Wants to enroll young healthy ppl since costs will be lower (favorable selection)

42
Q

Part D

A

Partial drug coverage
Subsidizes costs of prescription drugs for Medicare beneficiaires
Part of Medicare Prescription Drug Improvement Act (MMA) of 2003
Coverage is all by private insurers with little regulation

43
Q

Medicare Administrative Contractors (MAC)

A

Single contracted payer to enforce regulations and coordinate payment for services

44
Q

Recovery Audit Contractors (RACS)

A

Contract with federal government to identify fraud and recover overpayment of funds

45
Q

National Coverage Decision (NCD)

A

Decision made at federal level broadcasted nationally to providers about what is covered if a benefit is not clear

46
Q

Local Coverage Decision (LCD)

A

Coverage decision made by contractor (MAC), cannot override NCD

47
Q

Supplemental Security Income (SSI)

A

NOT MEDICARE
Monthly amt paid by social security, gives money to ppl with limited income and resouces to buy food, clothing, shelter
SSI benefits not same as social security benefits
Person must be disabled, blind, age 65 or older and unable to work

HCD (5 decks)

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