Medicare/ Medicaid

Question	Answer
medicare established	-1965 -part of social security act
medicare qualifications	-65 years old -2 years disabled -end stage renal failure
PPS	-prospective payment system -payment for services provided to a Medicare patient is fixed with adjustments made annually. Payment is based on assigned DRGs
MDS	-minimum data set -a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility. The MDS contains items that measure physical, psychological and psychosocial functioning. The items in the MDS give a multidimensional view of the patient's functional capacities and helps staff to identify health problems.
IRF-PAI	-inpatient rehab facility patient assessment instrument -assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge. IRF-PAI items address the physical, cognitive, functional, and psychosocial status of the IRF patients. The data collected for IRF-PAI is used for quality of care purposes and items were developed primarily for IRF prospective payment system (PPS)
RUGs	-resource utilization groups -any of 44 classifications patients are assigned to that determine reimbursement -determined by number of days and number of disciplines involved
acute hospitals under medicare	-reimbursed under DRGs
inpatient rehab facilities	-reimbursed under IRF PPS, data collection for reimbursement under IRF-PAI, 60% compliance threshold, 4 tier reimbursement rates based on acuity and cormobidity
SNF under medicare	-reimbursed through SNF PPS, data collection through MDS, 44 tiers of payment through RUGs
medicare advantage programs	-similar to Medicare, but managed by private HMO companies
HMO	-health maintenance organization -provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities in the United States and acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.
ARD	-assessment reference date -the specific end point of look-back periods in the MDS assessment process.
custodial care	-not covered by medicare, non-skilled personal care like ADLs
rules for therapy	1) medical necessity 2) skilled service 3) reasonable and necessary
inpatient psych under medicare	-reimbursement based on DRG
medicare part A	-hospital insurance -pays for skilled care -requires 3 night stay -7 days/week nursing -5 days/week therapy -covers inpatient stays -no monthly costs to beneficiaries
DRG	-diagnostic related groups -group of patients classified for measuring a medical facility’s delivery of care. Based on primary and secondary diagnosis, primary and secondary procedures, age, and length of hospitalization.
HDHP	-high deductible health plan -form of catastrophic coverage -higher deductible than other plans
ACOs	-accountable care organizations -made up of hospitals, physicians, specialists, and others, such as home health care. The ACO contracts to manage the quality and cost of care for a minimum of 5,000 Medicare beneficiaries for 3 years. The hope is that ACOs will save Medicare money by managing care better.
medicare part B	-medical insurance -covers doctor’s services and outpatient care -billed by CPT (current procedural terminology) codes -$3700 threshold -people pay a set fee per month and 20% of costs after a yearly deductible. -therapy cap covering rehab services. Services can’t go beyond this or people must pay out of pocket. -voluntary program -covers some medical equipment (DME- durable medical equipment)
medicare part D	-prescription insurance -paid for by monthly premiums
medicaid	-for low income individuals -insures older adults, children and parents of dependent children, pregnant women, and people with disabilities who meet the eligibility requirements. -majority of recipients are children and Medicaid covers ¼ of all children in the US. - 2/3 of Medicaid spending goes to older adults and the disabled -pays for 2/3 of all nursing home residents in the US -provides support to 4 in 10 children with special needs -jointly financed by federal and state governments -means tested program, as people qualify if their assets and income levels are below standards set by the program -OT is an optional service under Medicaid

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	Created by Diana Fitts about 9 years ago