Medicare

Question 1

Medicare

Answer 1

-retirement health benefit

Question 2

Features of Medicare

Answer 2

• uniform standards across all states for eligibility and benefits
• made up of:
• -A (inpatient)
• -B (outpatient)
• -C (medicare advantage)
• -D (prescription drug benefit)
• -Medicaid

Question 3

Medicare Part A:

What’s Covered

Answer 3

• Inpatient care in hospitals & critical access hospitals
• first 100 days in SNF
• Home health care if homebound
• Hospice Care

Question 4

Medicare Part A:

Who’s Covered

Answer 4

• > 65 years old
• some <65 with disabilities (totally disabled)
• End-Stage Renal disease (ESRD)

Question 5

Medicare Part A:

Premiums

Answer 5

• $0 if worked more than 40 quarters (10 years)

- 1% of beneficiaries if worked less than 40 quarters

Question 6

Medicare Part A:

Hospital Costs

Answer 6

• $1,260 deductible for each benefit period (annual)
• Days 1-60= $0 coinsurance
• Days 61-90=$315 coinsurance per day
• Days 91-150=lifetime reserve days ($630 per day, up to 60 days over pts lifetime)
• Beyond reserve days=pt pays cost

Question 7

Medicare Part A:

SNF Cost

Answer 7

• No deductible
• Day 1-20=$0 coinsurance
• Days 21-100=$157.50 coinsurance per day
• Days 100+= all cost to pt

Question 8

Medicare Part A:

Home Health Costs

Answer 8

• No deductible

- 20% of medicare approved amount for durable medical equipment

Question 9

Medicare Part A:

Hospice Cost

Answer 9

-$0

Question 10

Medicare Part A:

Outpatient Rehab Costs

Answer 10

• 20% coinsurance based on Medicare physician fee schedule

- what we bill is irrelevant

Question 11

Medicare Part A:

Funding

Answer 11

• federal payroll 2.9% tax paid by employees and employees
• each pay % of employee’s income to fund Part A
• 1.45% paid by employee
• 1.45% paid by employer

Question 12

Social Security:

Funding

Answer 12

• retirement income benefit
• funded same as Medicare Part A
• tax rate=12.4%
• 6.2% by employee
• 6.2% by employer

Question 13

If you’re a private contractor then:

Answer 13

-you pay entire 2.9% and 12.4%

Question 14

IRF

Answer 14

-inpatient rehab facility

Question 15

IRF Requirements

Answer 15

• pt must receive 3 hours of PT-OT-SLP per day at least 5 days/week
• 60% of ALL pts (medicare + nonmedicare) must fall within 1 of the 13 diagnostic categories

Question 16

If they don’t meet IRF requirements:

Answer 16

-DRG exemption will be removed and IRF will be paid DRG rates

Question 17

13 IRF Diagnostic Categories

Answer 17

-stroke
-SCI
-congenital deformity
-amputation
-major multiple trauma
-fracture of femure (hip)
-brain injury
-neurological disorders
-burns
+ 4 more

Question 18

SNF Requirement

Answer 18

• 3 day stay in an acute hospital bed
• skilled level of care still required (nursing &/or rehab)

-watch out for observation stays

Question 19

Medicare Part B:

What’s Covered

Answer 19

• physician services
• outpatient hospital care
• home health (if pt not homebound)
• covered supplies if medically necessary

Question 20

Medicare Part B:

Who’s Covered

Answer 20

• whoever enrolls (voluntary insurance plan by federal government)
• Most medicare beneficiaries sign up (inexpensive)

Question 21

Medicare Part B:

Costs

Answer 21

• Annual deductible: $147
• monthly premium: $104.90
• beneficiary pays 20% of allowable

Question 22

Medicare Part B:

Monthly Premium

Answer 22

• $104.90
• means tested-tied to annual income
• premiums rise if your income exceeds $85,000 single/$170,000 married

Question 23

Medicare Part B:

Funding

Answer 23

• enrollee programs

- allocations from general taxation

Question 24

Therapy Caps

Answer 24

• apply to all facilities
• Primary & Secondary Caps
• SLP + PT
• OT

Question 25

Mecicare Part C

Answer 25

• “medicare advantage”

- medicare replacement plans

Question 26

Medicare Part C:

Features

Answer 26

• must be in Part A and B
• allow to opt out of medicare and into HMO/PPO
• may offer expanded benefits (vision, hearing aids)
• medicare pays premiums to insurers
• put pt pays copay

Question 27

Medicare Part D

Answer 27

-prescription drug benefits

Question 28

Medicare Part D:

Features

Answer 28

• payment for prescription drugs

- Donut Hole

Question 29

Donut Hole

Answer 29

• Donut Hole: 75% covered up to $2,960
• Beneficiary Responsible for $2,961-$4,550
• 95% coverage after $4,550

Question 30

Medicaid

Answer 30

• medical insurance for the poor

- government

Question 31

Medicaid:

Mandated Services

Answer 31

• every state
• IP/OP hospital Services
• early/period screening, diagnostic and treatment services
• nursing facility services
• home health
• physician services
• rural health clinic
• federally qualified center
• lab/x-ray service
• family planning services
• nurse midwife
• certified pediatric and family nurse practitioner
• freestanding birth center
• transportation to medical care
• tobacco cessation counseling for pregnant women

Question 32

Medicaid:

Features

Answer 32

-variable enrollment eligibility/benefits based on state

Question 33

Medicaid:

Categorically Needy

Answer 33

• low income families with children
• people receiving SSI
• pregnant women, infants, children with income less than specified % of poverty level
• qualified medicare beneficiaries