Medicare/Medicaid Flashcards
Medicare made up of:
Part A (Inpatient) Part B (Outpatient) Part C (Medicare Advantage) Part D (Prescription Drug Benefit) Medicaid
What is Medicare’s share of the federal budget?
15%
What is covered in Medicare part A:
Home health care Hospice care Inpatient care in hospitals Inpatient care in critical access hospitals SNF
How many days are covered under Medicare part A in a SNF?
100 days
Who is covered under Medicare?
People age 65 or older
Some people under age 65 with disabilities
People with End-Stage Renal Disease (ESRD)
When does a benefit period begin?
begins the day you’re admitted as an inpatient in a hospital or SNF
When does a benefit period end?
when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.”
Premium for part A:
$0 for most people worked more than 40 quarters
Premiums if worked less than 40 quarters
What is the deductible for each benefit period?
$1316
Days 1-60 hospital:
$0 coinsurance
Dags 61-90 hospital:
$329 coinsurance per day
Days 91-150 hospital:
lifetime reserve days
$658 per day
Up to 60 days over patient’s lifetime
Beyond lifetime reserve days hospital:
all costs borne by patient
Amount of SNF deductible?
no deductible
Days 1-20 SNF:
$0 coinsurance
Days 21-100 SNF:
$164.50 coinsurance per day
Days 100+ SNF:
All costs borne by patient
Home Health cost per benefit period:
No deductible
20% of the Medicare approved amount for durable medical equipment
Hospice cost per benefit period:
$0 for hospice care
Cost outpatient rehab:
20% coinsurance based on the Medicare Physician Fee Schedule (MPFS)
What is Medicare Part A funded by?
a federal payroll 2.9% tax paid by both employees and employers
1.45% paid by employer and employee
Social Security tax rate:
- 4%
6. 2% by employer and employee
When do you no longer pay the social security tax?
When your gross pay exceeds $118,500 (in 2017)
PPS
Prospective Payment System
Medicare sets the price
IRF requirements:
Patients must receive 3 hours of PT-OT-SLP (or any combination thereof) per day at least 5 days per week
SNF requirement:
3 day Part A stay in an acute hospital bed
Skilled level of care still required (nursing, rehab)
What is covered under Medicare part B?
Physician services
Outpatient hospital care
Home health (if patient is not homebound)
Covered supplies if medically necessary
Cost of Medicare part B?
Annual deductible of only $183.00 in 2017
$109.00 monthly premium in 2017
What is means tested?
Is tied to annual income
What is Medicare part B funded by?
Enrollee premiums
Allocations from general taxation
Primary therapy caps:
$1,980 for PT + SLP
$1,980 for OT
change every year
Secondary therapy caps:
$3,700 for PT + SLP
$3,700 for OT
remains the same every year
Features of Medicare part C:
Medicare Advantage
Allows seniors to opt out of traditional Medicare & into HMOs or PPOs that have contracted with CMS
Medicare pays premiums to insurers
How do you qualify for Medicare Advantage?
Must have both Medicare A & B to qualify
Medicare Appeal Levels:
Level 1: Heath Plan Level 2: Independent Organization Level 3: OMHA Level 4: Medicare Appeals Council Level 5: Federal Court
Medicare Donut hole:
75% covered up to $3,701
Beneficiary responsible for $3,701 - $7,425
Is the “donut hole”
95% coverage after $7,425
Medicaid enrollment and benefits:
variable from state to state
Categorically needy:
Low income families with children
Individuals receiving SSI
Pregnant women, infants, and children with incomes less than a specified percent of the Federal poverty level
Qualified Medicare beneficiaries
SSI:
Supplemental Security Income: A Federally-funded needs-based disability program for adults and children which provides monthly cash benefits and, in most states, automatic Medicaid eligibility)
ACA Medicare expansion:
The uniform income requirement is a minimum of 133% of the federal poverty level for EVERYONE
