Healthcare Delivery Test Part 2

FMAP

Federal Medical Assistance Percentage (FMAP): formula to determine how much the state should pay and how much the government should pay for medicaid. Wealthier states --> less government assistance. formula by which federal government matches state Medicaid spending for beneficiaries eligible for Medicaid at least dollar for dollar. Varies by state based on per capita income

Max-copay rule in medicare

$30/visit

75% rule

- 75% rule was made but is now 60% rule. 75% of the patients you see have to be under 1 of the 13 categories in the next slides. This drove some kinds of care (musculoskeletal and other medical) away from IRF'S as seen in the graphs below. • Medicare pays IRFs at a higher rate than other hospitals because IRFs are designed to offer specialized rehabilitation care to patients with the most intensive needs. • CMS maintains criteria, such as the 75% rule to distinguish between IRFs and either acute care hospitals or SNF's that are paid under different a PPS system. • Known as the "75% Rule," the criteria: - focus on medical necessity and functional capability - require that inpatient rehabilitation facilities have at least a certain % of their admissions fall into 13 diagnostic categories. • As long as they meet the required % threshold, hospitals can still admit other patients with diagnoses not related to one of these 13 categories. - froze at 60% because of concerns about access --> A minimum of 60% of admissions to an IRF must meet the strict criteria

What is the incentive in a Fee For Service payment model? (financial incentives that providers take advantage of consciously or unconsciously)

- Encourages more services - Encourages more expensive services - Rewards proceduralists (specialists), not PCP's - Does not encourage prevention

What was the result of implementation of a DRG from a patient-care perspective? What is the financial incentive in order for the hospital to make a profit for a DRG?

- Incentive for quick d/c, minimization of costly care, minimization of staffing levels (?for PT?). - Led to shorter hospital stays, more demand for post-acute care. SNF, Acute Inpatient Rehab (IRF),Home Health. - Patients much sicker/more disabled upon discharge -Underutilization in order to save money which led people to go back into the hospital. Home health, SNFs, IRFs increased to take care of people who were discharged too quickly/reduced hospital visits

Example NCD Estim for wounds

- Medicare "will cover electrical stimulation for the treatment of wounds only for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers." - "The use of electrical stimulation will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing."

Qualifications for SNF

1) Inpatient who needs skilled nursing care, or other skilled rehab services on a daily basis, which can only be provided in a SNF 2) Prior "3 midnight stay" in hospital 3) Prior hospital stay transferred to SNF w/in 30 days - Possible they could "fail" a d/c home and be admitted to SNF

Conflicting incentives with RUG system based on 1)Medicare payments depend on the residents' RUG level 2) Do not vary with the actual costs of providing care.

1) to move residents into higher payment case-mix groups (higher RUG levels) - Higher RUG level EXPECTED to use MORE resources. - Recent concern that facilities are over utilizing higher case-mix groups---how does this correlate with the incentives under PPS? 2) to limit the cost per day of providing care.

13 categories for 75% rule

1. Stroke 2. Spinal cord injury 3. Congenital deformity 4. Amputation 5. Major multiple trauma 6. Fracture of femur (hip fracture) 7. Brain injury 8. Neurological disorders (including, but not limited to, MS, MD, polyneuropathy, and Parkinson's disease) 9. Burns 10. Active, polyarthricular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies 11. Systemic vasculidities with joint inflammation 12. Severe/advanced osteoarthritis involving two or more major weight-bearing joints (not counting joints with a prosthesis) with joint deformity, substantial loss of range of motion, and atrophy of muscles surrounding the joint 13. Knee or hip joint replacement, with one or more of the following circumstances applying: - Bilateral knee or bilateral hip joint replacement surgery during acute hospitalization. - Body Mass Index of at least 50 at time of admission to inpatient rehabilitation hospital. - Age 85 or older at the time of admission.

Medicare beneficiaries and spending: about ___% of the people take up _____% of the medicare spending

10% od the people use 57% of the medicare spending good target for health care reform to focus on the 10%

% of american budget on Medicare and medicaid

14% medicare 9% medicaid AARP does lots of lobbying for this and you can join at 50+

Medicare history

1965: created 1972: added to cover those with permanent disabilities 1970s: added ESRD and ALS (No waiting period if you have end stage renal disease or ALS)` 2015: 55 million disabled Now: ANYONE CAN GET MEDICARE REGARDLESS OF INCOME OR MEDICAL HISTORY

Dual eligible

20% dual eligible - over 65 and poor enough, or disabled and poor enough for Medicaid and medicare

8 minute rule

8 minute rule: if you do something for 8+ minutes it is billable. Anything less isn't billable. This led to medical professionals to start to give 8 minute interventions instead of 6 minutes. Only applies to fee for service and Medicare part B is fee for service. CMS Rule: CPT codes used for 1:1 care by therapists are coded according to the following times: • Number of units: corresponding time - 1 unit ("15-minute" unit) 8 minutes and through 22 minutes - 2 units 23 minutes through 37 minutes, - 3 units 38 minutes through 52 minutes - 4 units 53 minutes through 67minutes - Etc. If a service provided is less than 8 minutes, but the whole treatment session is much more than 8 minutes, can that time be billed for?

**Question: because Medicare part D has such a massive market share (capitalism), can the federal government negotiate with drug companies for lower costs on drugs?

????

Modifier

A code used on Medicare billing forms which indicates an important piece of information the provider needs to convey.'= • GA Modifier -ABN in place • 59 Modifier-CCI edit exception

Can we bill for services an aide has done (such as ultrasound) while being supervised by a PT?

A: No. Under Medicare Part B, services provided by an aide are never reimbursable, regardless of the level of supervision. The following language is included in the CMS Medicare Manuals: - Services provided by aides, even if under the supervision of a therapist, are not covered by Medicare.

ABN (Advanced Beneficiary Notice)

ABN: A signed notice letting the beneficiary know if you don't think Medicare will pay for something . The patient has to sign it. This happens when they have reached the cap and will go over it so medicare wont cover it anymore A notice provided by a health care provider which says Medicare probably (or certainly) won't pay for some services or items in certain situations. • The beneficiary will have to pay for the item or service if Medicare doesn't. • The beneficiary is asked to sign the ABN to say that they have read it and understand. • E.g. Patient wants to continue PT services beyond what is considered medically necessary or expected to be covered under the Medicare cap.

CCI 59 Modifier

Allows two codes that would usually not be accepted to be billed together DO NOT MEMORIZE MODIFIED NUMBER OR LETTER but just that it will allow two codes to be billed together. The Correct Coding Initiative (CCI) prohibits certain codes from being billed on the same date of service. • For many of these code pairs, you may add the 59 modifier to indicate that the services were performed during separate time intervals. • Reality, a real pain!

IRF PPS

Also uses weighted payment based on pt diagnosis and other factors • Uses a data collection instrument called the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) • The equivalent data collection instrument: - INF: PAI - SNF: MDS - Home Health: Oasis

Medicaid application process then and now

Before: all Medicaid had to go to office and fill out form to pay After: electronic

CCI Edits (correct coding initiative)

CCI: A system that shows which two codes will be billed together and which ones wont be rejected. These denied codes are linked to the ICD diagnosis. Example: 97530 + 97110 = we wont accept these two codes billed together. Correct Coding Initiative (CCI) - Developed by CMS contractor - to "promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims." • Purpose: to ensure the most comprehensive groups of codes are billed rather than the component parts. • Also, CCI edits check for mutually exclusive code pairs. These edits were implemented to ensure that only "appropriate" codes are grouped and priced.

CORF - certified outpatient rehab facility

CORF - more than just physical therapy but may have physiatrist,

Supplemental Security Income (SSI)

Cash payment to those who are disabled, blind, 65+ and unable to work. Provides cash for a specific treatment. NOT MEDICARE • A monthly amount paid by the Social Security Administration to people with limited income and resources who are disabled, blind, or age 65 or older and unable to work. • Provide cash to meet basic needs for food, clothing, and shelter. • SSI benefits are NOT the same as regular Social Security benefits paid after retirement age.

What does CMS stand for

Centers for Medicaid/Medicare Services

Part A SNF Coverage: what is covered and what is not covered?

Days 1-20 (must follow "qualifying" hospitalization) fully covered • 20-100 days, patients pay $164/day • After 100 days, no further SNF coverage. 3 night stay in hospital and then admitted to SNF and after that point they get 20 days completely paid for. After 20 days they have to pay $164, after 100 days they get no more coverage. Encouraged to stay 3 days in a hospital to get that full coverage at a SNG

What did medicare advantage do to gov. medical expenses?

Decreased 6%

DRGs: what are they

Diagnosis-Related Group is a specifics PPS used by medicare in acute care hospitals Classifies acute hospital cases (patients) into one of approximately 500 groups. ICD-9 diagnoses, procedures, age, sex, and the presence of complications or co-morbidities are used to categorize into DRG and thus determine payment level. - pts within each category • are similar clinically • are expected to use the same level of hospital resources.

Medicaid Eligibility after healthcare reform

Eligibility: after Healthcare Reform If Medicaid eligibility expanded by state: non-elderly adults with incomes at or below 138% of the federal poverty level (FPL=$15,060) - about $20,783 for an individual in 2017 Funding addition: provides for 100% federal funding of the expansion through 2016, declining gradually to 90% in 2020 and future years.

% of people in colorado who use medicare part C when they are eligable for it

Example: 35% of people in Colorado who are eligible for Medicare part C use it In rural areas it is very discouraged to use Medicare part C

Medicare Part B Covers what

Generally called: Medical Insurance, or Supplemental Medical Insurance • Covers: - Physician services - Outpatient care including outpatient PT - Ambulance Services - Some preventive services like Pap smear tests, flu shots, and prostate cancer screenings - Laboratory services/diagnostic testing

Spend down and long term care . What is this?

Have a million dollars in the bank and have to put money in the account that you have to continue to pay until you run into money. Not legal for someone to gift money to daughter and then try to get on Medicaid. Very emotionally devastating for older adults to go through this process.

Medicare Part B Coverage Costs

Have a premium of $134-428 based on income, $183 deductible, 20% coinsurance, Monthly premium $134 IF pt earns less than $85,000/yr • Premium increases if pt makes more with max of $428 if you make >$214,000/yr • Deductible: $183/yr • Co-insurance of 20% of the Medicareapproved amount (also called the Medicare Fee Schedule) for all services covered by Part B.

Medicaid role in health care

Health insurance Long term care assistance Support for health care system and safety net Assistance to medicare beneficiaries state capacity for health coverage

Medicare Part A hospital benefit

Hospital deductible ($1316) then bills paid fully x 60 days per illness. 60-90 days, pt pays $329/day 91-150 days, pt pays $658/day No further coverage after 150 days. - No "out of pocket maximum" Most people go onto Medicaid if they get sick for an extraneous amount of time because they spend all of their money for their health expenses.

If a patient meets his/her Medicare Cap, and presents a couple months later with a different condition, is it considered automatically excepted?

In cases where the services are appropriate and medically necessary, treatment during the same year for different conditions would be an exception from the therapy cap. - So the answer is "yes" if criteria met

Part C Medicare Advantage

Initially called "Medicare Choice Plus"...Now called "Medicare Take Advantage" • A health coverage choice run by private companies approved by Medicare - have to be eligible for part A and B to qualify • Includes services covered by Part A, Part B, and usually other coverage including prescription drugs and glasses • Costs for items and services vary by plan • May have alternative structures like co-pays insteadof co-insurance • Open enrollment (must accept anyone) EXCEPT ESRD who must stay in traditional Medicare

Medicaid mandatory minimum coverage

Inpatient and outpatient hospital services Physician, midwife, and nurse practitioner services Early and periodic screening, diagnosis, and treatment (EPSDT) for children up to age 21 Laboratory and x-ray services Family planning services and supplies Federally qualified health center (FQHC) and rural health clinic (RHC) services Freestanding birth center services (added by ACA) Nursing facility (NF) services for individuals age 21+ Home health services for individuals entitled to NF care Tobacco cessation counseling and pharmacotherapy for pregnant women (added by ACA) Non-emergency transportation to medical care

Long Term acute care hospital

Long term acute care hospital - individuals discharged to a inpatient hospital if they are ventilator dependent, usually medically recovering from something.

Medicaid coverage of long term care

Long term care: Medicaid pays for majority of them to live there and rest is cash pay or from long term care insurance. However long term care insurance is super underwritten. Long term care, (previously referred to as Custodial Care.) This is payment for LIVING in a nursing home. Very different than SNF coverage, which is primarily covered by Medicare Dual eligibles alone account for ~40% of all spending, driven largely by spending for long-term care

What patient/family or case manager "behavior" might you see at 19 or 99 days at a SNF facility using medicare part A?

Lots of discharges occur during this period.

Medicaid Eligibility before healthcare reform

Low-income individuals in certain categories: children pregnant women parents of dependent children individuals with disabilities people age 65 and older EXCLUDED "childless adults" This is still the coverage in states who have NOT expanded Medicaid under Healthcare Reform (19 states) States can decide to implement the Medicaid expansion at any time.

MACS

MACS - use private companies. Trailblazers bid to provide the administrative services for specific states. • Medicare Administrative Contractor (MACs) • Private companies • Single contracted payer to enforce regulations and coordinate payment for services for Medicare Beneficiaries. May hear terms "Trailblazers", "Highmark" etc. • Replaced "Fiscal Intermediaries" and "Carriers"-don't need to know this, but know that other terms may be out there.

What did elimination of FFS do to health care system?

Major savings losses Elimination of fee for service and creation of PPS payment systems in skilled nursing facilities. --> No incentive to do more and more for services. --> Largest loss of PT jobs because of loss of fee for service

Example NCD/LCD for Estim/Biofb for urinary incontinence

Medicare "will cover the use of pelvic floor electrical stimulation and biofeedback for Medicare patients with stress and/or urge incontinence for whom pelvic muscle exercise has not worked. • The use of biofeedback as a primary therapy for urinary incontinence will remain at the discretion of the private contractors that process and pay Medicare claims. "

Medicare Part A coverage

Medicare Part A: Hospital insurance No premiums as long as you + spouse have worked 40+quarters in life. Pay into system via taxes Primary Payer for acute care, SNF, home health, inpatient rehab, and hospice.

Medicare advantage costs more or less for federal government

Medicare advantage plans were costing 14% more for federal government.

What does medicare cover generally?

Medicare doesn't pay for room and board like assisted living but ONLY pays for heath expenses. It doesn't cover maintenance care/ADLs. Dental and Vision not covered

Catch to Part C when they say they will pay for Part A and B

Medicare part C - advertise that they will pay for part A and B and more (silver sneakers) but there is a catch - Very strong utilization review for SNFs

NPI and statistics tracking

Medicare tracks provider trends • If a provider falls on the high end in any one area or if there is a significant change in charging/reimbursement (called aberrant coding), more investigation is performed • This system helps Medicare find abnormalities and potentially root out fraud and/or abuse • Big focus as additional revenue to a financially strapped system. Examples: • NPI # used in multiple states in one date or a range of several days • NPI # used to bill for hemorrhoid removal 500 times on a single pt • # of CPT codes in one day charged for different beneficiaries would account for 5 days worth of care • "Provider location" is looked at via Google maps and found to be an empty lot

What does the future of Medicare hold? Obama, Bundled patment, Trump

Medicare wants to get out of Fee for Service and develop quality measures for some kind of payment. Obama administration CMS goal: elimination of procedure based payment (especially in Part B physician payment) Bundled payment - TKA/THA - MI and other cardiac conditions Trump Administration CMS goal: Unclear - Probably undo what Obama did

Examples of Supplemental Coverage?

Medigap: Pays $150 a month and is 100% covered for all services that Medicare part A and B cover but wont cover services they wont covered. Still wont cover past the Medicare cap. - Garanteed issue - Traditional "Medigap" plan • Covers all cost sharing for Parts A and B • Purchased from private insurers like United Healthcare (not sold by CMS) • Covers the patient portion of whatever Medicare determines is a "covered" service • Does not cover services that Medicare denies Employer Sponsored: get retirement benefits for the rest of your life. could be "Retirement benefit" from former employer, or health insurance purchased if still working Medicaid: dual eligibility if you are poor. supplement for the poor/disabled (also called "Dual Eligibles" Medicare advantage/part C plans: worst plan for all of the supplemental coverages because the patient has to pay the most out of pocket costs.

Part A: Inpatient Rehab Facility (IRF)

Must be: - clinically stable - able to tolerate at least 3 hours of rehab therapy (combined PT, OT, SLP) at least 5x/week. • 75% rule (now 60% rule)

Medicare Part B cap Exceptions Process

NO LONGER IN EFFECT Exceptions process: have a new medical event that is very different from the one that ran you to the cap then you can get an exception that gives you a new amount of money to spend on services. Used to be that if you get up to $3700 they will come and review. But that is now not in effect and it is just the $2010 cap without outpatient hospital services counting towards this. THIS IS CURRENTLY TRING TO BE REPEALED Automatic exception process (no manual exceptions process) - Utilize the automatic process for exception for any diagnosis for which provider can justify services exceeding the cap, between $1960 and $3700 - Biggest benefit: new diagnosis exception - Need covering documentation - KX modifier used - Over $3700 threshold, a "Manual Medical Review" process occurs before payment

NPI

NPI Number: unique for each person. Allow use to track disciplines National Provider Number • Providers unique identifier affixed to each and every charge/bill • Used to track any discipline across the states • Used to track patterns of charging and look for outliers

Is Custodial care covered under Part A? -May hear custodial care beds called "Part B beds" Why "Part B beds?"

Never covered Custodial care is covered under part B - Health care pays for rehabilitation like an outpatient service (Part B Beds)

Have all states expanded Medicaid under healthcare reform? What is the effect?

No 18 states have not Those who do note expand are leaving a large percentage of people uncovered in their states Example: South states have huge coverage gaps because they didn't expand medicaid .

Observation status Implications for PT in hospital, implication for eligibility to use part A benefits for SNF?

Observation status: Watch patient for 2-3 days to make sure they are stable and not considered inpatient treatment They are covered by Medicare Part B while they are on observation status. Instead of admission, the patient is kept on "observation status" by hospital - No risk of "readmission" where hospital is financially penalized - Paid under Part B benefits • Implications for PT in hospital? Observation stays have increased because hospitals are hesitant to admit people. Use as a financial strategy because the person can be readmitted • Implication for eligibility to use of Part A SNF benefits? Implications for SNF administration - wont get SNF visit paid for because they don't have the 3 day inpatient visit.

when is Medicare open enrollment

Oct 15-Dec 7

SNF overspending in the media

Over time we have increased the amount of ULTRA HIGH Rug status. --> not everyone admitted to ultra high facility has those needs. Example of people figuring out the system and pressuring PTs to put everyone in ULTRA HIGH RUG status.

Results of the 75% rule

Over time you saw a increase in Nervous system diagnoses at IRFs. Decrease in other medical and lower in musculoskeletal - Some IRF closure - Increased use of SNF facilities for individuals who previously were admitted to Inpatient Rehab Facilities (IRF) - Increased Neuro Rehab in SNF's and opportunity for employment

Part A: Home Health

PPS system Part A primary payer for home health care. in some instances part B will pay. Covered completely if meet certain requirements Requirements: - Homebound - Under care of physician - Requires skilled care of nursing, PT, or ST - OASIS documentation form

Medicare Part A use to be FFS and not dues Prospective Payment System (PPS) why?

PPS: Payment of a set amount to the provider/institution for each admission episode Done because of overutlization and overbiling of covers and was done to reduce health care costs. Started in acute care hospitals (DRGs)

What is covered if benefit is not clear? NCD/LCD

Part A or Part B - National Coverage Decision (NCD) - Medicare itself is making a decision if providing this coverage is a benefit • Made at the Federal Level • Broadcast nationally to providers - Local Coverage Decision (LCD) - If no NCD then a MAC can make a LCD to make a decision on whether something is covered or not. • Coverage decision made by the Contractor • Can not override a National Coverage Decision

Medicare Part D

Part D: drug coverage. All privately run plans - Paid for by Medicare - Subsidize the costs of prescription drugs for Medicare beneficiaries • Part of the Medicare Prescription Drug, Improvement Act of 2003 (MMA) and went into effect on January 1, 2006

Early Periodic Screening, Diagnosis and Treatment (EPSDT)

Part of Medicaid minimum coverage Covers all children ages birth to 21 Covers screening for physical, mental, developmental, dental, hearing & vision problems Covers additional diagnostic tests when risks are identified

What does PPACA stand for

Patient Protection and affordable care act

Healthcare reform and Medicare

Payment reduction to Medicare Advantage providers so that, on average, Medicare no longer pays out more than traditional Medicare plan. • When you hear people talk about "cuts to Medicare benefits" in Healthcare Reform, sometimes they mean these cuts. Let's discuss...

Duel eligibles

People who qualify for medicare and medicaid 15% of medicaid enrollees (11 million people)

Original reason for IRF

Provide intensive therapy to those requiring it What it became-chance for facility to make more money than they would if operating a SNF Fee for service was higher than SNF's. What was the financial incentive? Admit everyone you can! When SNFs went to PPS we started sending everyone to IRF to pay for care. This drove people to IRFs

RACS

RACS: Companies who contract with federal gov. to identify fraud and recover overpayment of funds. Super aggressive since they always make money based on how much they recover. Recovery Audit Contractors • Contract with the Federal government to identify fraud and recover overpayment of funds

RUG IV allows for what 3 kinds of therapy and what do the groups determine?

RUG IV rehabilitation categories → classification driven 1° by minutes of therapy received/week • Allows that there are 3 "types" of therapy delivery (don't get 1:1 credit if therapist is not seeing them 1:1) 1) Individual 2) Concurrent • No more than 2, both of whom must be in line-of-sight of the treating therapist • Minutes divided amongst individuals, as opposed to counting as 1:1 for each person 3) Group-2-4 individuals performing similar activities

Medicaid optional coverage

Rehabilitation Services (PT, OT, Speech) Prescription drugs (all states) Dental care Durable medical equipment Personal care services (e.g. CNA to get person with quadriplegia up in morning, to bed at night) Home and community-based (HCBS) long-term services E.g. assisted living, adult day care, respite services for family providers - temporary housing for someone who is normally living with family member.

Risk adjustment in medicare

Risk adjustment: Medicare pays Kaiser a maximum amount of money for patient under Medicare part C plan. If person is a little more sick they will get more money for that patient.

SNF vs custodial care facility

SNF - usually in nursing home but not always - for short term (20 day visit) rehab patients - Primary payer is Medicare part A benefit Custodial care facility - long term patients there for life - Primary payer is for Medicaid, because costs are so high - If they want rehab they cant get it because they don't have part A medicare

SNF financial incentives change with PPS: RUG system

SNF PPS = RUG levels=MDS 3.0 ("Case mix classifications - Patient but into RUG level based on rehab and nursing needs - used to determine how much provider gets paid for entire treatment of a patient (PPS) Covers the costs of all patients' needs, including medications, supplies, nursing, rehabilitation therapies, and even the sheets Minimum Data Set (MDS) 3.0: Resident assessment contains info on the beneficiary's nursing needs, Activities of Daily Living (ADL) impairments, cognitive status, behavioral problems, and medical diagnoses - Determines RUG level which in turn determines PPS payment

Medicare is for what two things?

Safety net hospitals and health center that serve LOW INCOME COMMUNITIES Coverage and financing for nursing home and community based long term care

Medicare coverage/financing basics

Single largest source of health coverage in the U.S. Covers ~ 73 million Americans - up 27% since ACA Administered by the STATES within broad federal requirements Jointly financed by states and the federal government

Medicare Direct Access

THEY NEED TO SIGN A PLAN OF CARE BUT REFERRAL NOT REQUIRED Almost yearly, bills are introduced to allow payment by Medicare of direct access services for Medicare beneficiaries. • Currently, a referral is not required... HOWEVER, a plan of care MUST be signed and in the pt chart within a certain time period of initiating care of a pt. • Medicare Direct Access is being fought by the AMA...

How is Part B paid for?

Taken from social security(premiums) of those on the plan but it is only covering 25% of the costs and 75% from general tax. Insurance premium withheld from Social Security check of all those voluntarily participating in plan. • Nearly all Seniors elect Part B. • Premiums collected covers 25% of plan - ($ 134/month in 2018) • Remaining 75% comes from general tax revenues

Medicare Part B Therapy Cap

There is an annual maximum use of PT and Speech ($2010) and a separate amount for OT ($2010) As of Jan 1, 2018, PT and SLP combined $2010; OT $2010 • The comma made it so PT and SLP get combined $2010 • Pt responsibility: - The deductible, then 20% of $2010=$ pt responsible for (based on "allowable charges", not billed amount) Cap did not include hospital based outpatient therapy

Traditional Medicare vs Medicare Advantage vs Drug Benefit

Traditional: Part A (hospital insurance) + Part B (medical insurance) Medicare advantage: part C Drug: Part D

RUG categories

Ultra high 720 hrs $559 Very high 500 hrs $445 High 325 hrs $383 Medium 150 hrs $341 Low 45 hrs $325

What is the incentive in a Flat Rate payment model?

Underutilization of services because they get same amount of money for a service

Medicaid waivers

Waiver: waive of typical rules. May consider covering these additional people. Child has Medicaid and family has regular insurance. Not going to do anyone any good to bankrupt family to pay for child's care. Individuals or children with disabilities can go on Medicaid. - Waiver allows child to live at home State based waiver programs approved federally Medicaid waivers "waive" a family's income so that their children may access medical care through Medicaid (the child's income is used in determining eligibility, not the family's) The CHILD must not have an income over $2200, nor assets of more than $2,000.00. Colorado currently has several Medicaid waiver programs for children with developmental, intellectual and physical disabilities who reside with their family. Extensive wait lists: each waiver has an enrollment limit &, thus, has its own waiting list (can be in the hundreds) For children who need a "level of care" that would "normally" be provided in a hospital, nursing home or institution will qualify

Part C plan pools

Want a healthier pool overall. Insurance companies that stuck around and stayed in the pool got favorable selection and those that didn't got adverse selection You can switch back and forth between Medicare advantage and Medicare plans SNFs don't have to agree to be in network for Medicare advantage plans because they don't get paid as much and would rather have regular insurance people come in • Rushed to create plans and enroll beneficiaries - Especially healthy, younger ones. Why? - Back to "what is the incentive" or how does the company make the most money for shareholders? 2 outcomes - Favorable selection -enrollees are "healthier than average" and therefore costs are lower. (Company makes $, stays with plans) - Adverse selection -enrollees are "sicker than average" and therefore costs are higher.(Company loses $, usually drop plans) • Examples in our market: Kaiser, Secure Horizons (Pacificare/UHC), Humana

Incentives and providers basics: how do providers respond to new healthcare policy (FFS, FFE, HPO, etc...)

What does it mean when I say that a particular "setting" has a financial incentive to X, Y or Z, because they are paid in a certain way? - Consider the financial/business incentive with all payment systems you learn about... - And, remember, every change is in response to people's inherent ability to "figure out" how to work the system...and government's response to the resultant increase in cost

Medicare Part B Coverage requirements on a PT

a. Physician (regardless of state licensure direct access laws) must sign POC for patient to receive PT b. Level of complexity & sophistication, or patient's condition require skills of a qualified therapist c. Medical record must contain active written treatment with goals d. Treatment plan should describe specific therapeutic interventions *e. Amount, frequency & duration of therapy should be reasonable & necessary for patient's condition f. Provided by a PT, or by a PTA under supervision of a licensed physical therapist (no aides). g. Therapy must require the skills of a physical therapist, but does not require that the patient's condition will improve substantially over time. See "Improvement Standard" below h. Therapy will only be covered until therapist or physician concludes patient is not going to improve.

Medicaid spending over time

dependent on health of the economy which makes it very difficult to budget for

Medicare has ______ cost sharing and _______ _______

high; benegit gaps Does not cover all medical benefits - Very limited long-term care coverage (no custodial care coverage) - No dental, hearing aids or eyeglasses Has relatively high cost-sharing requirements - Deductibles for Part A, Part B, and Part D - Coinsurance/copayments - Part D coverage gap No limit on out-of-pocket spending Pays about half of beneficiaries' total health and longterm care spending

What did adding medicare part B do to government expenses?

increased 10%

Do states have to cover children under medicaid?

yes

How is Part A financed?

• 1.45% payroll tax levied on all workers, matched by employer (total 2.9%) • Self-employed pay the full amount • Placed in "Medicare Part A trust fund. 1.45% on all workers and employers --> 2.9% which is put into Medicare part A trust fund which pays for the amount

What types of services, NOT PAID FOR BY MEDICARE, MAY occur in nursing homes?

• Assisted living or adult day care: : facility where loved one goes to a facility where they have activities for them. • Custodial care: Colorado costs per month: - Minimum: $5262 - Median: $6996 - Maximum $19,771

Concerns of Medicare Coverage

• Coverage is all by private insurers with little regulation on how plans are instituted. • Very confusing for a group that is generally not tech savvy and many times ill. • "Doughnut hole" where coverage occurs early and late, but not in the middle has been a problem: one of first "fixes" in ACA

Legislation of the Medicare Part B cap

• Every year, new legislation is introduced to repeal the cap • Every year so far, we have to settle for an extension of the automatic exceptions process • Because Congress did not continue to take action, the ORIGINAL cap goes back into place. • AND THE REQUIREMENT ALSO EXPIRED FOR HOSPITALS-SO ALL SETTINGS HAVE A CAP EXCEPT HOSPITALS • What does that look like for patients? Example: Has surgery in January and stroke in June and runs out of money (spends all of the $2010) through the cap. For the first time in 15 years we have a hard cap at $2010

SNF response to PPS system and backlash for putting people in HIGH RISK GROUPS

• Look for alternative ways to generate income or reduce costs • Many Nursing Homes have opened outpatient services for recently d/c'd patients, to supplement Part A income - Paid for by Medicare Part B outpatient benefit

PPS in the SNF's started in 1999: altered the financial incentives from fee for service to PPS: - What were the old incentives? - What are the "new" incentives under PPS?

• Old-The more care provided, the more money comes in • PPS-reward providers for delivering care efficiently

Supplemental Coverage with Medicare

• There is significant Cost-Sharing in the Medicare program. • In 2015, 90% of beneficiaries obtained some supplemental coverage in addition to Part A and B. • This 90% DOES INCLUDE those in a Medicare Advantageor Part C plan (more in a minute) • The 10% without supplemental care, disproportionately: - under‐65 disabled - the near poor (annual incomes between $10,000 and $20,000) - rural residents - black race Employer-sponsored insurance: Premiums have gone up and so employers are less likely to pay for a lifetime of coverage for these people so this number is going down.