Medicare Flashcards
Medicare
-retirement health benefit
Features of Medicare
- uniform standards across all states for eligibility and benefits
- made up of:
- -A (inpatient)
- -B (outpatient)
- -C (medicare advantage)
- -D (prescription drug benefit)
- -Medicaid
Medicare Part A:
What’s Covered
- Inpatient care in hospitals & critical access hospitals
- first 100 days in SNF
- Home health care if homebound
- Hospice Care
Medicare Part A:
Who’s Covered
- > 65 years old
- some <65 with disabilities (totally disabled)
- End-Stage Renal disease (ESRD)
Medicare Part A:
Premiums
- $0 if worked more than 40 quarters (10 years)
- 1% of beneficiaries if worked less than 40 quarters
Medicare Part A:
Hospital Costs
- $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
Medicare Part A:
SNF Cost
- No deductible
- Day 1-20=$0 coinsurance
- Days 21-100=$157.50 coinsurance per day
- Days 100+= all cost to pt
Medicare Part A:
Home Health Costs
- No deductible
- 20% of medicare approved amount for durable medical equipment
Medicare Part A:
Hospice Cost
-$0
Medicare Part A:
Outpatient Rehab Costs
- 20% coinsurance based on Medicare physician fee schedule
- what we bill is irrelevant
Medicare Part A:
Funding
- 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
Social Security:
Funding
- retirement income benefit
- funded same as Medicare Part A
- tax rate=12.4%
- 6.2% by employee
- 6.2% by employer
If you’re a private contractor then:
-you pay entire 2.9% and 12.4%
IRF
-inpatient rehab facility
IRF Requirements
- 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
If they don’t meet IRF requirements:
-DRG exemption will be removed and IRF will be paid DRG rates
13 IRF Diagnostic Categories
-stroke
-SCI
-congenital deformity
-amputation
-major multiple trauma
-fracture of femure (hip)
-brain injury
-neurological disorders
-burns
+ 4 more
SNF Requirement
- 3 day stay in an acute hospital bed
- skilled level of care still required (nursing &/or rehab)
-watch out for observation stays
Medicare Part B:
What’s Covered
- physician services
- outpatient hospital care
- home health (if pt not homebound)
- covered supplies if medically necessary
Medicare Part B:
Who’s Covered
- whoever enrolls (voluntary insurance plan by federal government)
- Most medicare beneficiaries sign up (inexpensive)
Medicare Part B:
Costs
- Annual deductible: $147
- monthly premium: $104.90
- beneficiary pays 20% of allowable
Medicare Part B:
Monthly Premium
- $104.90
- means tested-tied to annual income
- premiums rise if your income exceeds $85,000 single/$170,000 married
Medicare Part B:
Funding
- enrollee programs
- allocations from general taxation
Therapy Caps
- apply to all facilities
- Primary & Secondary Caps
- SLP + PT
- OT
Mecicare Part C
- “medicare advantage”
- medicare replacement plans
Medicare Part C:
Features
- 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
Medicare Part D
-prescription drug benefits
Medicare Part D:
Features
- payment for prescription drugs
- Donut Hole
Donut Hole
- Donut Hole: 75% covered up to $2,960
- Beneficiary Responsible for $2,961-$4,550
- 95% coverage after $4,550
Medicaid
- medical insurance for the poor
- government
Medicaid:
Mandated Services
- 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
Medicaid:
Features
-variable enrollment eligibility/benefits based on state
Medicaid:
Categorically Needy
- low income families with children
- people receiving SSI
- pregnant women, infants, children with income less than specified % of poverty level
- qualified medicare beneficiaries
