Payment for OT Services Flashcards
Medicare: Who is eligible? (4)
- Persons over 65yrs
- Individuals of all ages with end stage renal disease/permanent kidney failure
- Persons with long-term disability (e.g. ALS, MS)
- Retired railroad workers
Medicare: Part A - what does it pay for? (5)
Pays for inpatient hospital, SNF, home health, rehabilitation facilities, & hospice care
Medicare: Part B - what does it pay for? (5)
Pays for hospital outpatient physician & other professional services including OT provided by independent practitioners
Medicare: Part B - is considered what?
Supplemental Medical Insurance & must be purchased by beneficiary, usually as a monthly premium
Medicare: Part A - How is one covered?
Anyone covered by the Social Security System that meets the crtieria
Medicare: Part A - How does it pay out for acute care? (5)
- Rate is determined by diagnostic related group (DRG)
- The DRG covered all services
- It is a fixed dollar amount regardless of length of stay
- Treatment supplies (AD, DME) are included
- Individual hospitals will determine the combo of services patient will receive
Medicare: Part A - Does the patient help pay for services?
Yes, Part A has specific time limits & also require deductible & coinsurance payments by the beneficiary
Medicare: Part B - Does the patient help pay for services?
Yes, there is no specific time limit & the patient is required to pay for 20% of service (co-payment)
Medicare: Criteria for coverage of OT services
- Prescribed by MD
- Performed by qualified OT/OTA w/ supervision
- Must be reasonable & necessary for tx of individual’s illness or injury
- Dx can be physical or psychiatric or both (no limits)
- OT must result in significant, practical improvement in the person’s level of functioning within a reasonable period of time
Does Medicare cover long-term, chronic illness?
The Medicare program recognizes the need for skilled care and related services for chronic, long-term conditions. For care to be covered, the patient must require skilled services which may be designed to:
Maintain the status of an individual’s condition; or
Slow or prevent the deterioration of a condition; or
Improve the individual’s condition
What is Medicare Home Care?
OT is covered if the individual is homebound & needed intermittent skilled nursing care, PT, or ST before they are eligible to receive home care OT (they are trying to change this barrier to service)
Homebound status criteria (4)
- person cannot leave the house (may be due to need of ambulatory devices, assistance of others, or special transportation
- if the person leaves the home it requires “considerable & taxing effort”
- person may leave home for medical apts (e.g. dialysis) or short-term & infrequent non-medical apts (e.g. haircut)
- the need for adult day care does not preclude a person from receiving home health services
What is Outcome & Assessment Information Set (OASIS)?
Required initial assessment - must be completed to verify the person’s eligibility for Medicare home health benefits & the continuation of service
It must be completed within 48hrs of the referral or person’s return home
Medicare & DME, Prostheses & Orthoses (5)
- Rental or purchase of DME is covered if used to improve functioning
- MD prescription needed
- The DME must be used for medical purpose & generally not needed in absence of disease or injury
- Self-help items, bathtub grab bars, & raised toilet seat are not reimbursable - other ppl use them & not medically necessary
What is Medicaid?
State/federal health insurance program for persons who have an income below an established threshold and/or have a disability
