Week 4 highlights Flashcards
True or false: Medicaid (poor ppl) is federally and state funded, Medicare (old ppl) is only federally funded
True
History of health insurance; what did the following people do?
1) Nixon (1960s-1970s)
2) Carter (1970s)
1) Expanded Medicare eligibility to include those with end stage renal disease and on dialysis
2) Medicare and Medicaid moved into the same agency in 1977, CMS (Centers for Medicare & Medicaid Services)
History of health insurance; what did the following people do?
1) Clinton (1990s)
2) G.W.Bush (2000s)
3) Obama (2000s-2010s)
1) HIPAA and the State Children’s Health Insurance Plan (CHIP) for children whose families didn’t qualify for Medicaid but couldn’t afford private insurance
2) Created Medicare Part D extending pharmaceutical coverage to outpatient prescriptions
3) Patient Protection and Affordable Care Act (ACA, ObamaCare)
Private insurances all have what?
Actuarial Value
Actuarial value is the percentage of total average costs for covered__________ that will be paid by a health insurance plan
benefits
Who would be more likely to want a plan with a higher actuarial value?
Elderly and sick ppl
True or false: Persons 19-64 who qualify only based on income do not qualify for Medicaid
True
True or false: Being low income is a requirement of medicaid, but not medicare
True
List 3 things covered by Part A of medicare
1) Covers inpatient care received in a hospital or skilled nursing facility
2) Home health care
3) Hospice care
Give an example of supplemental Medicare coverage
Medigap
Medicare part _______ covers the actual vaccine vial, and part __________ covers the jab
B; D
Who is not permitted to enroll in Medigap insurance?
Those with part C medicare
When can you enroll in Medicare?
3 months before or 3 months after your 65th birthday month
(7 month initial enrollment period window)
If you enroll in Medicare 3 months before your 65th birthday month, when would your coverage begin?
The first of your birthday month
If you enroll in Medicare 3 months after your 65th birthday month, when would your coverage begin?
The first of the following month
Define disability
The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Health professionals play a _____ role in the disability determination process and participate in the process in a variety of ways
vital
Define “Incident to” billing
A Medicare billing provision that allows services provided by PAs in an office or clinic to be reimbursed at 100% of the physician fee schedule, as opposed to the typical 85%.
How is “Incident to” billing achieved?
By attributing services provided by PAs to the physicians with whom they work after a series of Medicare-specified conditions are met:
1) The physician personally performing either the history, exam, or medical decision making (in its entirety)
or
2) The physician spending more than half of the total time by both the physician and the PA (or NP) on face-to-face and non-face-to-face patient care activities.
As of Jan 1, 2022 Tennessee PAs receive ______ reimbursement from Medicare
direct
Why is a payer mix important?
Because Medicare and Medicaid pay hospitals less than what it costs to treat patients.
Pay mix: %____________by taking the total payments for the financial class, provider, service location, and/or__________and dividing it by the total amount of payments for the entire search results
calculate; payer
List some categories of QI/RM
1) Surgical or Invasive Procedure Events
2) Product or Device Events
3) Patient Protection Events
4) Care Management Events
6) Environmental Events
7) Radiologic events
8) Potential criminal events
Medication errors: Use_______________________ for medication, radiology, and laboratory orders.
CPOE (computerized physician order entry)
