Medicare Flashcards
Who qualifies for Medicare?
- Anyone > 65
- Disabled + ESRD
Who qualifies for Medicaid?
- low income
- disabled
- individuals in long term care
Source of funding for Medicare
- Federally-run
- Publicly funded
- Contributions via payroll taxes are made during the years of employment.
Source of funding for Medicaid
federal/state cost sharing
How is short SNF paid for?
- Medicare 1st 100 days
How is long SNF paid for?
- Medicaid (can after spend down)
Medicare Part A is?
Inpatient service
Medicare Part B is?
Outpatient service
Medicare Part C is?
Medicare Advantage
Medicare Part D is?
Prescription drug coverage
How long of inpatient does part A pays for?
- first 60 days
- hospital paid a fixed amount regardless of LOS
- Does not pay for long term custodial care
T of F? Long-term SNF care is not paid by Medicare
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Does part A pays for rehab?
- only if hospitalized for 3 midnights
- first 20 days: 100% coverage
- 21-100: co-pay required
- > 100 days: none
How does part C work?
- government pays an insurance organization to manage Part C
- Combines Part A + Part B with some additional coverage
How does part D work?
- optional Rx plan
- Average monthly premium $31
- Plans vary in what drugs are covered
T of F? 90% of Medicare enrollees purchase supplemental private insurance coverage to reduce costs.
- Deductibles, co-pays, and medications can be expensive
What are some of the mandatory coverage by Medicaid?
- acute + preventive services
- screening, immunization
- medication
- labs, x-rays
- family planning, prenatal + maternal health
- dental
- inpatient care
T of F? Medicaid pays for most long-term nursing home care?
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Compared to commercial rate, what does medicare and medicaid pay?
- Medicare: 80%
- Medicaid: 80% * 66%
How does Medicare and Medicaid determine reimbursement?
prospective payment system
What’s the reimbursement system for Inpatient care?
DRGs - fixed amount
What’s the reimbursement system for Inpatient care?
Relative value units - RVUs
What are the 3 relative value units?
- MD work expense: care time+ skill
- Practice expense: equipment + supplies
- Malpractice expense
What are examples of “never events” that medicare will NEVER pay for?
pressure ulcer stages III and IV
falls and trauma
surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery
vascular-catheter associated infection
catheter-associated urinary tract infection
administration of incompatible blood
air embolism
foreign object unintentionally retained after surgery
What is ICD?
International Classification of Disease
- generated by WHO
- Diagnosis or Symptom Classification
What is CPT?
Current Procedural Terminology
- licensed by the AMA Service Codes – procedures, evaluations, management