L2 Insurance and Aging Flashcards
Medicaid
state allocated
low income
custodial care or health care
Medicare
federally funded
age/condition
health care
Medicare Overview
-federal health insurance program
-funded by payroll withholdings and premiums
-recipients are over 65, have ESRD, a disability, or ALS
-has four parts
Medicare Part A
-Covers hospital/IRF, skilled nursing, home health, and hospice
-very specific criteria for coverage
-short-term treatment/coverage
-usually no premiums, but deductibles/copays
-does not cover caregiver costs
-uses benefit periods, not benefit calendars
2024 Deductible for Medicare Part A
$1632 per benefit period
How many days can you spend at the hospital without a cost with medicare A?
60
How many days can you spend at the SNF without a cost with medicare A?
20
What two services under medicare part A are free no matter the amount of days?
Home health
Hospice
Hospital Coverage Criteria for Medicare Part A
-Admitted to hospital
-Doctor’s order/note for necessity
-hospital accepts medicare
covered until inpatient level of care no longer needed, and covered as a flat rate
Inpatient Rehab Facility Coverage Medicare Part A
-doctor indicates necessity
-patient can do 3 hours of rehab per day
-PT is helpful because it helps with successful discharge
Skilled Nursing Facility Criteria for Medicare Part A
-hospital admission of 3 midnights
-doctor’s note of necessity
-has to have services within 30 days of hospital discharge
-has to have a need for skilled services during hospital stay
-max stay is 100 days
Benefit period for SNF
episode of care beginning with hospital admission and ending 60 days following last covered day of skilled services.H
Home Health Criteria for Medicare A
-must be homebound
-can be to prevent decline or improve function
-skilled services are required on part-time basis
Medicare Part A Section GG
standardized assessment that evaluates self care and mobility
Medicare Part A Hospice Criteria
-patient is terminally ill
-6 mo or less to live
-focus on comfort rather than curing
-medicare covers everything that is needed for terminal condition, additional insurance for non-terminal conditions
Medicare Part B
Optional insurance that can be purchased by >65 yo or disabled
has premiums ($175 per month) and Deductible ($240 per year)
covers outpatient services, medically necessary services, and preventative services
PT in Medicare B
has a limit of $2330, and then must be proved to be a medical necessity to continue. combined with SP
after $2330, you have to add the KX modifier threshold to signifiy that ongoing treatment is a medical necessity
billed as eight minute rule (each treatment has to be at least 8 minutes)
Professional Claims
reduction for that therapist’s services
Institutional Claims
reduction for all services
Medicare Part C
-private insurance that is medicare approved that cover the services that medicare does
-offer medication, dental, and vision benefits
-could be more economical than medicare
What percentage of medicare advantage enrollees have united healthcare or humana?
47%
More people have…
medicare advantage than traditional medicare
Medicare Advantage
special needs plans that provide benefits/services that are tailored to best meet the beneficiaries
Types of Medicare Advantage
- D-SNP Dual Eligible = medicare and medicaid
- C-SNP Chronic Condition
- I-SNP institutional: long term care, assisted living
Pros of Medicare Advantage
-limited deductibles
-may waive 3 day hospital stay
-coverage of extra services
-clear provider network
-motivation for prevention services
-may have alt payment models
Cons of Medicare Advantage
-prior authorization
-limited provider network
-variability in plan/cost/coverage
-case-managed care
-motivation to limit services
