Medicare Flashcards
(10 cards)
Original Medicare includes:
- Part A (Hospital)
- Part B (Medical)
- Supplemental insurance
- Part D (prescription drugs, optional)
Medicare Part A
-Hospital
-Does not cover dental or vision
Covers:
- Inpatient care
- Skilled nursing facility stays
- Hospice care
- Some home-health services
Medicare Part B
-Medical
-Does not cover dental or vision
Covers:
- Outpatient hospital services
- Doctor’s office visits
- Durable medical equipment
- Ambulance services
-Cost of Part B varies with income
Medicare Advantage (Part C)
Managed-care alternative to Parts A and B that covers the same care
-Sometimes covers dental and vision services
-Hospitalization + Medical + RX + vision/dental/hearing
-Need preauthorization
Copayment before visits
-Narrow networks
-Private health insurance plans paid by federal govt
-Medicare Advantage is mostly HMOs and PPOs (Preferred Provider Organizations)
Supplemental Coverage
Called “Medigap”:
Extra health insurance you can buy from a private company to help cover out-of-pocket costs that Original Medicare (Parts A and B) doesn’t pay for.
These costs can include deductibles, co-pays, and coinsurance
Medicare costs
-No out-of-pocket limits, yes deductibles & copayments
-Coverage limitations:
- All “reasonable and necessary” services
-Determined through CMS evidence-based process
- No cost-effectiveness consideration
Inpatient Prospective Payment System (IPPS)
-Each inpatient case categorized into a diagnosis-related group (DRG)
-Each DRG has a payment weight assigned to it, based on average resources spent on treating Medicare patients in DRG
-Hospital gets paid fixed amount based on the DRG, regardless of how much $ it spent on patient.
Hospital Outpatient Prospective Payment System (OPPS)
-A system used by Medicare to pay for outpatient services provided in hospital outpatient departments and some other settings.
-It’s a “prospective payment system”, meaning that payments are determined in advance based on pre-set rates, rather than being based on actual costs incurred
Value-based purchasing program
Adjusts IPPS pmt based on achievement & improvement scores
