Exam 1 Flashcards
3 enrollment ways to get Medicare
- automatic
- open
- must sign up
Medicare Automatic Enrollment
- getting benefits from Social Security or Railroad = automatically get Part A and B when you turn 65
- under 65 and receiving disability. automatically get after have disability benefits for 24 months
- you have ALS. get when disability benefits begin
Medicare Open enrollment
generally btw october and december
- time when you can make changes to your plan
Medicare: must sign up enrollment
- not eligible for social security or RRB
- you have ESRD
- enrollment period (initial = 7 month period beginning 3 months before 65th and 3 months after; general = can sign up btw jan 1 and march 1 but pay more; special = no late penalty, covered under employment at time so didn’t sign up)
• Know the criteria that makes a person eligible for Medicare
i. People 65 and older
ii. People under 65 with certain disabilities
iii. People of any age with end stage renal disease (ESRD)
iv. U.S citizen or lawfully present
Medicare A : covers?
inpatient hospitals, SNF, hospice and home health
Medicare A : premiums
- most don’t pay. paid in with taxes
- premium would be $407/month
- late fee - inc 10% for 2 times the # of years didn’t sign up
Medicare A : benefit period
- eligible for 90 days of hospital followed by 100 days of SNF during same period
- no limit to number of benefit periods
- lifetime reserve = 60 days
- resets after 60 days free of treatment
Medicare B: covers
therapy, screening, diagnostic testing, physician services, prosthetics/orthotics, DME
Medicare B:Premiums
- monthly based on income
- late fee = inc 10% for each full 12 month period not enrolled
Medicare B: Co-pay amount
80% by medicare, 20% by indiv
Medicare B: minimal content for POC
diagnosis long term goals (LTGs) type amount duration freq
Medicare B: certification
- Initial POC certified within first 30 days (signature or verbal)
- If verbal need to follow up within 14 days with a signature
- Initial period can be for 90 calendar days from initial eval
- Re-cert every 90 calendar days
is Med B optional?
yes. can opt out.
Med A: acute care hospital
-90 day benefit period
days 1-60 = $1260 and no coinsurance
days 61-90 = $315 per day (co-insurnce)
after day 90 = $630 per lifetime reserve day
after reserve = pay all costs
*psychiatric care = 190 days in a lifetime
Covers: bed & board, nursing, drugs, supplies, tests, therapy. (Part B covers doc services while in hospital)
Med A: inpatient rehab requirements
a. Requires multiple therapy disciplines (PT,OT,ST, orthotics)
b. 1 needs to be either PT or OT
c. needs to tolerate 3 hrs of therapy a day at least 5 days per week
d. certain cases may need at least 15 hrs within a 7 consecutive day period
****Interdisciplinary team conference min once per week
What is the 60% rule and where does it apply?
- Med A inpatient rehab
- 60% of people need to fall within 13 categories within any given year to be reimbursed by medicare
Med A: SNF benefit period, requirements, additional info
- Entitled to 100 days per benefit period
a. Pay nothing for first 20 days
b. Next 80 days coinsurance ($157.50/day) - Requirements
a. Min 3 days (midnights)
b. Transferred to SNF within 30 days of hospital discharge - Additional info
a. Requires physician certification/re-cert
b. Services can be stopped for up to 30 days and resumed w/o re-hospitalization
c. Once 100 days are up. Need a 60 day break to reset benefit period.
SNF - 4 factors to meet in order to be covered
- requires skilled services
- requires on daily basis
- services can only be provided in SNF
- reasonable and necessary
Med A - hospice info
- for terminally ill. life expectancy = 6 months or less
- certification = two 90 days periods. then unlimited 60 day periods
- reimbursement based on level of care
Med A - home health
- must meet homebound requirements by physician (can’t leave home, not safe to leave home)
- certification (60 day episodes, first 100 visits paid under part A. rest paid under Part B
Assessment and reassessment = initial, reassess progress every 30 days. Reassess prior to 14th and 20th visit
Med A: student services in SNF
- if student is deemed adequate, and CI not treating anyone, CI does not need to be present
- concurrent therapy: CI direct line of sight
- group therapy: direct supervision
Med B: student services
-CI has to do everything. Student services not billable.
How can student care be reimbursed by Med B?
- practitioner is present in there for entire session
- PT makes all clinical decisions
- PT responsible for all parts of care
- Student is guided by practitioner
Medicare Advantage plans: coordinated care plan
- HMO
- PPO
Medicare Advantage plans: coordinated care plan. HMO =
- defines network to use
- more restrictions
- does not cover out of network
- in network = cheeper, to no cost
- Exception for emergency or urgent care away from home
Medicare Advantage plans: coordinated care plan. PPO =
- network
- similar to HMO in that you get full coverage in network
- **Point of service (POS) - option allows you to go out of network but for more costs
