Reimbursement Test 1 part 3

rad2329's version from 2016-09-22 19:53

Section 1

Question Answer
With Medicare Part A when would (SNF) Skilled Nursing Facility Care be covered?When a patient requires skilled nursing or rehabilitative services occuring within 30 days of a 3-day-long or longer acute hospitalization and is certified medically necessary.
With Medicare Part A explain what number of SNF days are covered and what the payment portion required by the patient?100 days per benefit period, fully covers the first 20 days in a benefit period, 21-100 days: A co-payment ($144.50 per day in 2012), benefits expire after the first 100 days during a benefit period.
Medicare Part A - Home Health Care covers what?Care provided by a Home Health Agency (HHA) may be furnished Intermittent or Part-time in the patient’s residence, Certain other therapies or rehab care, Medical supplies and durable medical equipment (DME).
Medicare Part A - Hospice what is required for a patient to be eligible?Certification by their attending physician for life expectancies to be six months or less, The patient must forgo standard Medicare benefits for treatment of their terminal illness and to agree to receive only hospice care.
For Medicare Part A - Hospice what is covered?Pays for all covered services necessary for a condition that is not related to the terminal illness. No deductible for the hospice coverage, but does pay co-insurance amounts for drugs and inpatient respite care. Respite care is any inpatient care provided to the hospice patient for the purpose of providing primary care-givers a break from their care-giving responsibilities.
Medicare Part A - Blood coverage is ?Beneficiary is responsible for paying fees to cover the first three pints or units of nonreplaced blood per calendar year, has the option of paying fee vs. family or friends donating blood.
What is Medicare - Part B used for?To pay for physicians’ services, medical services, and medical-surgical supplies not covered by the hospitalization plan.
What can most individuals over 65 who are ineligible for Medicare Part A coverage choose to do?Enroll voluntarily by paying a monthly premium for Part A when they also enroll in Part B.
What services and supplies are covered by Medicare - Part B?Physicians’ and surgeons’ services, including chiropractors', podiatrists, dentists, optometrist, and Medicare approved practitioners, ie. CRNA, Clinical social workers, psychologists, PAs. Services in ED or outpatient clinics, including same day surgery and ambulance services. Home healthcare not covered under Medicare Part A. Lab tests, x-rays, and other diagnostic radiology services.
List specific services and supplies covered by Medicare - Part B?Ambulatory Surgery Centers, Physical and Occupational Therapy and Speech Pathology Services, Comprehensive outpatient rehabilitation facility services and mental healthcare provided as part of a partial hospitalization program, Radiation Therapy, renal dialysis, and kidney transplants, and heart and liver transplants, DME approved for home use, such as oxygen, wheelchairs,dressings, etc., Drugs and biologicals that cannot be self-administered, such as hepatitis B vaccines, Preventive Services such as bone mass measurements, cardiovascular screening, screening mammograms, etc., Inpatient hospitalization when Part A benefits have been exhausted.
What must happen for Medicare Part B services and supplies to be covered?All services must be either documented as medically necessary or covered as one of several benefited preventive benefits, Deductibles and/or co-insurance required for most services, Special payment rules are in play for certain medical services.
What services are NOT covered by Medicare Part A and B?Long-term nursing care, Cosmetic surgery, Dentures and dental care, Acupuncture, Hearing aids and exams for fitting hearing aids.

Section 2

Question Answer
What would you use to pay for services not covered by Medicare A or B?Private Health Plans under Medicare Advantage program.
What does Medicare Advantage, Part C, (MA Plans) expanded coverage take care of?Services not covered under Medicare A or B, Vision, Hearing, Dental, Healthcare Wellness Programs. Must meet specific requirements as determined by CMS.
Medicare Advantage Part C include what type of MA plans?Health Maintenance Organization (HMO), PPO Plans, Private fee-for-service plans, Medicare specialty plans.
Explain/Describe Health Maintenance Organization (HMO) ?You can only go to doctors, and other healthcare providers or hospitals on the plan’s list of approved providers
Explain/Describe PPO Plans.Patients use doctors, specialists, and hospitals in the plan’s network and can go to doctors and hospitals not on the list, usually at an additional cost.
Explain/Describe Private fee-for-service plans.Similar to Medicare in that you can generally go to any doctor, other healthcare provider, or hospital as long as they agree to treat you.
Explain/Describe Medicare Specialty Plans.These plans provide focused and specialized healthcare for specific groups of people, such as those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic conditions.
What is Medigap?Private health insurance that pays, within limits, most of the healthcare service charges not covered by Medicare Parts A and/or B. Policies must meet federal and state laws.
What was signed into law on December 8, 2003?Part D - The Medicare Prescription Drug, Improvement, and Modernization Act, also known as the Medicare Reform Bill.
Medicare - Part D plans are run by insurance companies and other companies approved by Medicare, each plan can ?Vary in cost and drugs covered, and beneficiaries select their preferred plan.

Section 3

Question Answer
What was enacted in 1965?Title XIX of the SSA, Medicade.
Title XIX pays for ?Medical assistance to individuals and families with low incomes and limited finances.
What governments work to provide Medicaid?Stage governments work with Federal medicaid programs.
Medicaid (Title XIX) must meet what?Broad guidelines established by federal statutes, regulations, and policies to qualify for Federal matching grants under the Medicaid program.
Policies on Medicaid eligibility, services and payment are ?complex and vary according to state.
Medicaid eligibility criteria is based on ?Categorically needy eligibility groups.
List 4 of the 8 categorically needy eligibility groups for Medicaid?Those who meet the requirements for Temporary Assistance for Needy Families (TANF), Children below six whose family income is at or below 133 percent of the federal poverty level, Pregnant women whose family income is below 133 percent of the Federal Poverty Level, Supplemental Security Income (SSI) recipients in most states.
List 4 of the 8 categorically needy eligibility groups for Medicaid?Recipients of adoption or foster care assistance under Title IV-E of the Social Security Act. Specially protected groups (typically individuals who lose their cash assistance). Infants born to Medicaid eligible pregnant women. Certain low-income Medicare beneficiaries
The medically needy option for Medicaid eligibility allows what? States to extend Medicaid eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups except that their income and/or resources are above the eligibility level set by their state
What must a state's basic services for a Medicaid medical assistance program offer to be eligible for Federal matching funds?Inpatient hospital service, Oupatiant Hospital services, Emergency services, Prenatal care, Vaccines for children, Physician’s services, SNF Services persons aged 21 or older.
What must a state's basic services for a Medicaid medical assistance program offer to be eligible for Federal matching funds?Family planning services or supplies, Rural Health Clinic Services, Home Healthcare for persons eligible for skilled nursing services, Laboratory and x-ray services, Pediatric and family nurse practitioners services, Nurse-midwife services, Federally qualified health center services and ambulatory, Early and periodic screening and diagnostic and therapeutic services for children under age 21.
This ACT came about in 1997?The Balanced Budget Act (BBA), it also called for implementation of a state option called (PACE) Programs of ALL-Inclusive Care for the Elderly.

Section 4

Question Answer
What does PACE provide?An alternative to institutional care for individuals 55 years old or older who require a level of care usually provided at nursing facilities.
Where can PACE services be provided?In day healthcare centers, homes, hospitals, and nursing homes.
What does the PACE program help to do?It's beneficiary's to maintain their independence, dignity, and quality of life.
Programs of All-Inclusive Care for the Elderly (PACE) offer and manages ?All of the health, medical, and social services needed by a beneficiary and mobilizes other services, as needed, to provide proventive rehabiliative, curative, and supportive care.
Comparison of Medicare and Medicaid programs: Age qualifications - Medicare age 65 or older; people under 65 who are entitled to medicare because of disability - Medicaid people of any age.
Comparison of Medicare and Medicaid programs: Administered through - Medicare through fiscal intermediaries, insurance companies under contract to the government to process Medicare claims. Medicaid administered by the federal government through state or local governments following federal state guidelines.
Comparison of Medicare and Medicaid programs: Regulations are - Medicare the same in all states. Medicaid vary from state to state.
Comparison of Medicare and Medicaid programs: Financed - Medicare by monthly premiums. Medicaid by federal, state, and county tax dollars.
Comparison of Medicare and Medicaid programs: Eligibility -Medicare for people aged over 65, based on SS or Railroad Retirement participation, for under 65 based on disability, for people who undergo kidney dialysis eligibility is not dependent on age. Medicaid based on financial need.
Comparison of Medicare and Medicaid programs: Payment - Medicare beneficiary responsible for paying deductibles, coinsurance or copayments and Part B premiums. Medicaid can help pay Medicare deductible coinsurance or copayment and premiums.
Comparison of Medicare and Medicaid programs: Benefits - Medicare hospital and medical benefits; preventive care and long-term care benefits are limited. Medicaid comprehensive benefits include hospital, preventive care, long-term care, and other services not covered under Medicare such as dental work, prescriptions, transportation, eyeglasses, and hearing aids.

Section 5

Question Answer
What is Title XXI of the SSA?State Children's Health Insurance Program (SCHIP). Sometimes referred to as the Children's Health Insurance Program, or (CHIP).
Title XXI of the SSA was initiated by ?BBA
What does the State children's Health Insurance Program SCHIP, (also known as CHIP Children's Health Insurance Program allow states to do ?Expand existing insurance programs to cover children up to age 19. Provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children.
When did SCHIP become available and who funds it?Became available on October 1, 1997 Jointly funded by Federal Government and States.
State Children's Health Insurance Programs must meet what 3 eligibility criteria:They must come from low income families, must be otherwise ineligible for Medicaid, must be uninsured.
Title XXI of the SSA, SCHIP (CHIP) states are required to offer what services? Inpatient Hospital Services. Outpatient Hospital Services. Physicians’ Surgical and Medical Services. Laboratory and x-ray Services. Well-baby/child care services including age-appropriate immunizations.
Tricare is formerly known as ?CHAMPUS Civilian Health and Medical Program of the Uniformed Services .
Who is Tricare for?Active-duty service members, National Guard and Reserve members, Retirees, their families, survivors, and certain former spouses.
What are the three plans offered by TRICARE?TRICARE Prime, TRICARE Extra, and TRICARE Standard
The TRICARE plan depends on ?Eligibility and where the individual lives.

Section 6

Question Answer
The Veterans Health Administration is the component of the ?U.S. Department of Veterans Affairs that implements the medical assistance program of the VA.
Eligibility for VA benefits is determined by a system of eight Priority Groups.Retirees from military service. Veterans with service-connected injuries or conditions rated by VA. Purple Heart recipients.
The Veterans Health Administration is the nations largest integrated healthcare system, it operates more than ?1400 sites of care, such as hospitals, clinics, community living centers, domicilaries, readjustment counseling centers, and various other types of facilities
What does CHAMPVA stand for?Civilian Health and Medical Programs – Veterans Affairs (CHAMPVA)
What is CHAMPVA?A healthcare program for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died from service-related conditions, and survivors of military personnel who died in the line of duty.
CHAMPVA is a voluntary program that ?Allows beneficiaries to be treated for free at participating VA healthcare facilities.
The IHS is responsible for providing healthcare services to ?American Indians and Alaska natives.
IHS staff or private healthcare professionals provide what ?Preventive healthcare services, primary medical services (hospital and ambulatory care), community health services, substance abuse treatment services, and rehab services.
IHS facilities operate on ?Indian reservations and in Indian and Alaska native communities.
In locations where the IHS does not have its own facilities or is not equipped to provide a needed service, it contracts with ?Local hospitals, states, and local healthcare agencies, tribal health institutions, and individual healthcare providers.

Section 7

Question Answer
Workman's Copmensation covers healthcare costs and lost income associated with ?Work-related injuries and illnesses.
Federal employees are covered by ?Federal Employee's Compensation Act (FECA).
______ pass legislation that address worker's compensation coverage for nonfederal government employees.Individual states.
Federal employes are covered by ?FECA
The Indian Health Service (IHS) is an agency within the HHS