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AL 254 Part 3

Reimbursement services

What is a beneficiary? A person who has health insurance through Medicare or Medicaid or a private health insurance company.
What is a deductible? Amount an individual must pay for health care before the health care plan begins.
What is a third party-payer? Any payer for health care services other than the individual receiving care.
Public Third party payers? Medicare, Medicaid, CHIP, Grants (IDEA), TRICARE Veteran's Adminstration, Worker's Comp.
Private Third party payers? Health Insurance, self-pay.
What are the Eligibility requirements for Medicare? Legal U.S. resident for at least 5 years, you or your spouse pay Medicare taxes for at least 10 years, 65 years or older and entitled to social security benefits, people with disabilities, people with ALS.
Medicare Part A? Hospital insurance. Automatic with no monthly premium, coverage includes: hospital inpatient, hospital long term care, skilled nursing facility, home health care, hospice care, services are bundled due to PPS.
Medicare Part B? Outpatient insurance. Designed to complement Part A, covers medically necessary services and some preventative services, Reimbursed through Medicare Physician Fee Schedule.
Medicare Part C? Medicare Advantage Plan. Managed Care similar to HMO or PPO, Monthly Premiums co-pays and co-insurance.
Medicare Part D? Prescription Drug Benefits. Monthly premium based on income.
What are some of the items that are not covered by Medicare? Long-term care, Routine dental or eye care, dentures, cosmetic surgery, acupuncture, hearing aids and exams for fitting them, routine foot care.
Medigap insurance? Supplement to medicare benefits-covers out of pocket expenses-deductibles, regulated by state and federal laws. Generally don't cover long-term care, vision, hearing aids, eyeglasses or private duty- nursing.
What is Medicaid? Title XIX of Social Security Act- provides health care to the poor and medically indigent. Jointly funded by federal and state, sate administered. 2 categories of service mandatory 1. OT only if Medically necessary. 2. OT/PT/SLP-optional free standing.
Medicaid waivers? Waivers allow some flexibility in the states in how to adminster their medicaid programs and services. Home and community based waivers allows beneficaries to receive long-term care in community settings. Waivers vary by state.
Kansas Medicaid? Can be either managed care or fee for service.
Children's Health Insurance Program (CHIP)? Funded under XXI of Social Security Act. Jointly funded by federal and state, administered by the state. Provides health coverage to children and some pregnant women in families with incomes too high to qualify for Medicaid but who can't afford private.
What are the minimum included benefits for CHIP? Inpatient and outpatient hospital services, physician's services, surgical and medical services, lab and x-ray services, well baby and well child care including immunizations, some dental services.
Kansas Health Wave? Combined program that includes Medicaid managed care and CHIP.
Medical Necessity? These should be in the evaluation or reevaluation:severity, complexity, previous medical care, beneficiary's opinion of health status, social support available to beneficiary.
Quantify using objective tools
Justify skilled level of services, reasonable and necessary, not just because "ordered by the physician."
Skilled treatment inherently complex- ex. muscle re-ed., needs case management- based on function and functional outcomes, cannot be performed by a layperson, medically complicated.
Reasonable and Necessary Expect improvement, acceptable standards of practice, maintenance, patient family instruction.
Possible Triggers for Review No substantial progress, not skilled, inappriorate supervision of support personnel, continues at same level of ability, disciplines contradict each other, duplication of services and maintenance.
Created by: lcurtis
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