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chapter 14

PACE Program of All-inclusive Care for Elderly
The goal of PACE is to help people remain independent and live in their community as long as possible.
The largest single medical benefits program in the U.S. is Medicare
The Privacy Act of 1971 regulates ROI (release of information)
A demonstration/pilot program is a special project that tests improvements in Medicare coverage, payment and quality of care
Medicare savings programs help people with low income and asset levels pay for health care coverage
The Centers for Medicare and Medicaid Services (CMS) is responsible for the operation of the Medicare program and for selecting Medicare Administrative Contracts (MAC)
The benefit period was formerly known as 1) spell of illness or 2) spell of sickness
Medigap is designed to supplement Medicare benefits by paying for services that Medicare does not cover
A benefit period begins the first day of hospitalization and ends when the patient has been out of the hospital for 60 days.
Medicare Part A covers institutional providers for inpatient services
Medicare Part B Physician services, outpatient hospital and other services not covered by Medicare ( also home health services if patient is not covered by part A)
Medicare Part C Medicare Advantage Plan....If you join a Medicare Advantage Plan, the plan will provide all of your Part A ( Hospital insurance) and Part B ( Medical Insurance) coverage.
Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness program. Most include Medicare prescription drug coverage ( Part D)
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.
However, each Medicare Advantage Plan can charge different out-of pocket costs and have different rules for how you get service ( like whether you need a referral to see a specialist or if you have to go only doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent). These rules can change each year.
Medicare Part D prescription drug coverage plan
Individuals 65 or over don't pay a monthly premium for Medicare Part A if they or their spouse paid Medicare taxes while working
General Medicare eligibility requires an individual or their spouse to: 1) Be at least 65 years old 2) Be a citizen or permanent resident of the U.S. 3) Have worked at least 10 years in Medicare-covered employment
A person can also qualify for Medicare services if they are younger than 65 years old if they are disabled or diagnosed with ESRD (end-stage renal disease.)
Annual Medicare deductible is $135
Special incentives mandated by Congress to increase the number of healthcare provider agreements with Medicare include: 1) Direct payment of all claims 2) Publication of PAR (participating provider) directory to all Medicare patients 3) 5% higher fee schedule
General enrollment period is held January 1st through March 31st each year
Hospice care is provided when the provider is unable to do anything further to stop the progression of disease and the patient is only treated to relieve pain/discomfort (palliative care)
Medicare limits hospice care to four benefit periods 1)Two periods of 90 days each 2) One 30 day period 3) A final "lifetime" extension of unlimited duration
RVU Relative Value Unit...where resources such as physician work, practice expense, malpractice expenses are taken into consideration when calculating physician fee schedules.
Patients can join the Medicare Prescription Plan by paying a monthly premium and annual deductible
Medicare cost Plan Individual receives healthcare from a non-network provider; original Medicare plan covers the services
Medicare Savings Account money managed by Medicare-approved insurance company
Patients confined to a psychiatric hospital are allowed 190 lifetime reserve days instead of the 60 days allotted for stay in an acute care hospital.
Initial Enrollment Period provide opportunity to enroll in Medicare before the age of 65
Respite Care is temporary hospitalization of a terminally ill patient to provide relief for the nonpaid caregiver
Medicare Select Medigap insurance that requires enrollees to use a network of providers in order to receive full benefits
When a patient selects Medicare hospice benefits stop with the exception of physician services for treatment for conditions not related to the patients terminal diagnosis
During the periods final terminal hospital stay there are 60 lifetime reserve days that may be used only once during a patient's lifetime and are usually reserved for this use
Medicare Advantage Managed care and private fee-for-service plans provided to Medicare patients
Benefit period beings the first day of hopitalization
Created by: drea08