Insurance & Reimbursement

Question 1

Medicare

Answer 1

1. Federal program that’s apart of the Social Security Act
2. Covers most adults age 64 yrs or older
3. Covers some people with disability younger than age 65
4. Covers people who have end-stage renal disease

Question 2

Medicare Part A

Answer 2

1. “hospital insurance”
2. Covers part of the expenses for inpatient stays in hospitals
3. Covers short-term stays at SNF for more acute conditions (up to 100 days, min 5 days/wk), hospice, and some services in HH
4. No monthly premiums because payroll taxes for individuals or their spouses have already paid for it

Question 3

Prospective Payment System (PPS)

Answer 3

1. PPS pays for medicare hospital services based on established diagnosis-related groups
2. PPS pays for Medicare Inpatient Rehabilitation Facility (Medicare IRF) services based on clinical characteristics and expected resources needs
3. PPS pays for Inpatient Psychiatric Facility services
4. OT must be medically necessary

Medicare Part A

Question 4

Outcome and Assessment
Information Set (OASIS)

Answer 4

1. Helps classify clients’ needs for home health agency
2. Helps determine payment for services

Medicare Part A

Question 5

Medicare Part B

Answer 5

1. Supplementary medical insurance
2. Covers cost of outpatient care
3. Covers some of home health care
4. Some supplies and equipment
5. Patient pays a montly premium
   6.** Medicare Part B covers 80%** of necessary outpatient PT/OT/SLP; patient pays any deductible not met and 20% of Medicare-approved costs

Question 6

Medicare Physician Fee Schedule

Answer 6

1. Based on payment for Medicare Part B: Outpatient services, HH, private practice, and physician visits
2. Uses Current Procedural Terminology (CPT) codes

Question 7

Medicare Part B Therapy Cap

Answer 7

1. Was repealed in 2018, but **threshold amount of $2,080 per year for OT ** still remains
2. Payments **above threshold are billed with KX modifer **and must be medically necessary
3. Claims exceeding $3,000 in a year are subject to a target review

Question 8

DME, AE

Answer 8

1. Covered under Medicare Part B
2. Medicare/Patient payment 80/20 split

Question 9

Medicare Part C

Answer 9

1. Medicare Advantage Plan offered by private company that contracts with Medicare
2. OT coverage TBD by specific policy requirements

Question 10

Medicare Part D

Answer 10

1. Presription drug coverage to original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans

Question 11

TRICARE

Answer 11

1. Part of Military Health System
2. Provides coverage for active-duty service members, retirees, their families, survivors, and certain former spouses
3. Nonmilitary and military providers are able to provide services
4. Coverage for OT services may vary depending on the specific regional plans

Question 12

Medicaid

Answer 12

1. state and federal health coverage
2. coverage for low income/resources
3. coverage for people with disabilities
4. Early and periodic screening, diagnosis, and treatment for ppl younger than 21 yrs of age (OT included)
5. Covers SNF, including OT for individuals age 21 or older

Question 13

State Children’s
Health Insurance Program
(CHIP)

Answer 13

1. Funded by federal and state gov.
2. Covers children in low income families
3. Covers children in families with income too high to qualify for Medicaid
4. OT coverage varies from state to state

Question 14

Individuals With Disabilities
Education Act (IDEA)

Answer 14

1. Available for free to eligible children with disabilities t/o U.S.
2. Governs how states and public agencies provide early intervention, special ed, and related services

Question 15

IDEA Part B

Answer 15

covers children and young adults with disabilities ages 3-21

Question 16

IDEA Part C

Answer 16

provides early intervention services to infants and toddlers ages 0-36 months

Question 17

Indvidual Education Plan (IEP)/
Individual Family Service Plan (IFSP

Answer 17

OT related services under IDEA Part B
and early intervention under IDEA Part C
must be provided according to the IEP/IFSP

Question 18

Medicare Catastrophic Coverage Act

Answer 18

allows related services to be billed to Medicaid though the school system under certain conditions

IDEA

Question 19

HMO

Answer 19

Health maintenance organization is a prepaid organized delivery system where organization and the PCP assume some financial risk for the care provided to its enrolled members

Question 20

PPO

Answer 20

Preferred provider organization allows people within their system to go directly to a specialist w/o going through a PCP

Question 21

POS

Answer 21

Point-of-service plans is similar to some of the HMOs, but it sometimes allows people to refer themselves to physicians who do not belong to the network

Question 22

Which part of original Medicare covers stays at hospitals and inpatient rehabilitation facilities?

Part A
Part D
Part B
Part C

Answer 22

Solution: The correct answer is A.

Medicare Part A covers stays at these facilities.

B: Medicare Part D added a prescription drug benefit and is not part of original Medicare.

C: Medicare Part B is part of original Medicare but covers outpatient care.

D: Medicare Part C or Medicare Advantage is not part of original Medicare.

Question 23

Which statement BEST describes the role of occupational therapy in an early intervention program under the Individuals With Disabilities Education Act Part C?

A] Occupational therapy is one of 17 primary services provided for children in need of early intervention services.
B] Occupational therapy is a related service provided only as a support to special education services.
C] Occupational therapy is provided as a fee-for-service intervention for children in need of early intervention services.
D] Occupational therapy is primarily a school-based service provided for children in need of early intervention.

Answer 23

Solution: The correct answer is A.

As part of IDEA Part C, occupational therapy is listed as a primary service, as are speech and physical therapy and special instruction. Early intervention services are for children ages 0 to 3 years.

B, D: These statements describe special education settings.

C: This statement refers to private service delivery settings.