Section 6/Week 6 Flashcards
Who is eligible for Medicare?
- all people age 65+
- all permanently disabled adults
- all people with End-Stage Renal Disease
Medicare Part A
Service plan: Healthcare paid directly by the government.
What kind of care does Medicare Part A provide?
Inpatient care, within hospitals.
How is Medicare Part A funded?
- Payroll taxes that fuel the Medicare Trust Fund, paid for by current working population for the elderly
- All elderly people pay a yearly deductible
- Employers match every dollar of Medicare tax paid by the employee
How are beneficiaries enrolled in Medicare Part A?
All people over the age of 65 are automatically enrolled.
Which services does Medicare Part A cover?
- In hospital care
- Skilled nursing home care for 20 days
- Hospice
How does Medicare Part A work with fiscal intermediaries?
Fiscal intermediaries are contracted to accept bills from the hospitals and are reimbursed by the Medicare Trust Fund.
Medicare Part B
Insurance Plan: Healthcare paid for by the patient, who is reimbursed by the government.
What kind of care does Medicare Part B provide?
Outpatient care, outside of hospital, physician care.
How is Medicare Part B funded?
Funding is complex and includes:
- Income taxes
- 20% co-payment from patient
- yearly deductible from patient
- 25% of premium from patient
How are beneficiaries enrolled in Medicare Part B?
Enrollment is voluntary.
How are fiscal intermediaries managed in Medicare Part B?
Fiscal intermediaries are contracted to accept bills from physicians (and practices) and are reimbursed by general tax revenues.
What is an allowable fee
The fee determined by the Center for Medicare and Medicaid to be appropriate for the service provided.
What does it mean if a physician is accepting
They will receive 80% of the allowable fee.
What does it mean if a physician is not accepting
They can charge the patient up to 115% of the allowable fee.
The patient is then reimbursed 80% of the allowable fee.
What is the personal contribution when you are enrolled in Medicare? Probably through Medigap Insurance.
- Part A deductible for each time in the hospital
- Part B yearly deductible $155
- 20% of allowable charges covered by Part B
- 25% premium
- If your physician IS NOT ACCEPTING, you will pay up to 115% of allowable charges and then be reimbursed for up to 80% of the allowable fee by Medicare (paying 35% total)
What is the societal contribution to Part B?
General tax revenues account for 75% of part B.
What is the employer contribution to part A?
For every dollar the employee contributes to the Medicare Trust Fund, the employer must match that dollar.
What are the four principal ways beneficiaries to obtain Medigap coverage?
- Private insurance (19% of beneficiaries do this)
- Retirement benefits from former employer (25%)
- Medicaid if eligible (19%)
- Medicare managed care plan (23%)
What are Resource Based Relative Value System/Unit (RBRVS/U)
A billing system used in Medicare for physician reimbursements. Each service has a particular RBRVU value. Each RBRVU equals a certain dollar amount. Congress can adjust the rate of each RBRVU.
What was the schedule of acceptable fees for physician services originally based on?
Original schedule of acceptable fees for physician services was based on a weighted average of what other physicians in the same community charged for the same service, referred to as the usual, customary, and reasonable (UCR) charge.
Original Part B payment schedule would pay physicians 80% of UCR. Due to rising costs, Congress asked for a study of revaluation which resulted in the RBRVU system.
What is the difference between RBRVU and PPS?
- PBRBU: doctor, outpatient services
- PPS: hospital inpatient services
What are the 4 components of the RBRVU
- inflation
- change in # enrolled in FFS
- GDP per capita growth
- new legislation
How are RBUs regulated by the government?
The sustainable growth rate (SGR) adjusts per RVU based on the % the aggregate exceeds the global budget.
