Health Care Systems, Medicare & Medicaid

1. Health Care Systems, Medicare & Medicaid PTP 783 Module 3

2. History of US healthcare • 1935: Congress began to look in to a national healthcare program • 1949 (Truman) administration • Controversial, but later targeted to just elderly • 1965 House Ways & Means Committee brought forth 2 amendments to the SSA: Titles 18 Medicare & 19 Medicaid

3. Evolution of Geriatric Reimbursement:Medicare • Title 18 of Social Security Act 1965 • Provide protection against cost of hospital and related care aged >65 who are entitled to SS retirement benefits – Medicare A • Permit >65 y.o. to purchase protection against the cost of physician services, one-half of the cost to be paid by the federal government – Medicare B

4. Evolution of Geriatric Reimbursement:Social Security • Title 19 of Social Security Act • Federal government matches cost of medical assistance for medically indigent aged person for all needy persons for whom the state is receiving federal grants - Medicaid

5. Who Opposed the expansion of health care coverage? • AMA • AHA • Insurance reps • Management special-interest groups • The political right Sounds familiar?

6. Evolution of Geriatric Reimbursement • Balanced Budget Act 1997 • Effected PT Reimbursement in • SNF • Home Health • Hospitals • Outpatient • Medicare choice Plans • Inpt Rehab spared for about 3 years

7. The “Upside” to the Balanced Budget Act • Anti Fraud Laws • Billing for services not rendered • Anti Abuse Laws • Billing for services not considered “reasonable and necessary” • Appropriate documentation is a must • Skilled service requirement

8. Medicare & Medicaid

9. CMS: Centers for Medicare and Medicaid Services • Purposes: • To establish policies on coverage, eligibility, & reimbursement • To establish standards for providers • To provide program administration • To monitor the performance of contractors and states

10. Medicare is made up of: • Part A services: hospital, in-pt • Part B services: out-patient services • Part C (Medicare Advantage plans) HMOs • Part D: Medications

11. Do you have to be over 65 to have Medicare? • NO • Stipulations: • Over 65 who is eligible for Social Security • Railroad retirement benefits or • Disability benefits for greater than 24 months • Chronic renal disease

12. Why is it important for physical therapists to be familiar with the rules defining skilled and nonskilled services for Medicare recipients?

13. Evaluation Reevaluation Ther ex Manual therapy Gait training ROM Ultrasound, E-stim Diathermy Paraffin Whirlpool Transfer training Establishing a FMP Restraint evaluation Orthotic training W/c training Pt & family training Vasopneumatic devices Infrared * (depends on intermediary) Skilled Rehab Services covered by Medicare:

14. Medicare Part A coverage • Hospital • First 60 days pay all but $1184 (deductible) • 61-90 days pay all but $296/day • 91-150 days pay all but $592/day (lifetime reserve days) • >150 days Medicare pays nothing • SNF • Medicare pays first 20 days at 100% • then 80% from day 21-100 up to $148/day • after 100 days Part A services pays nothing • Home Health • Pays 100% medically necessary services, and 80% DME • Must be home bound and under physician’s care • Hospice • Pays 100% except limited cost sharing for meds and respite care (5% discount off Medicare approved rate) • Has to be a Medicare approved hospice inpt facility (not the pt’s home or a SNF that is not approved) • Blood • Pays for first 3 pints furnished by hospital or SNF during a covered stay

15. Other issues with Medicare • Benefit period: begins on day 1 of hospital and ends after 60 days of wellness after d/c from hospital or SNF.

16. Medicare & SNFs • For Medicare coverage with PART A services the pt must have • A 3-day qualifying stay in the hospital • Require skilled services (PT, OT, ST, nursing) • If the pt is not directly admitted to a SNF after d/c from the hospital then he/she has 30 days to be admitted to the SNF for Part A services to cover her stay. • Care at SNF must be for the same dx as what pt was hospitalized for

18. Prior to PPS (1997) SNFs were paid in 3 different categories • Routine costs: room, nursing services, medical supplies, psyc & social services, & use of facility equipment • Ancillary costs: therapy, meds, labs • Capital related costs: cost of land *now it all bundled into one per diem rate

19. Medicare Assessments in SNFs Medicare requires SNFs to do periodic assessments throughout a patient’s stay to determine level of payment. AKA: PPS (Prospective Payment System)

20. Medicare RUG levels During those assessment periods the patient must fit into a RUG level (Resource Utilization Group)

21. Medicare Part B • Deductible: $147/yr • Medical Expenses • PT Services • 80% of hospital based services • All other PT clinics subject to therapy cap $1900 • Clinical Laboratory Services • Pays 100% • Home Health • 100%, DME is 80% • OP Hospital Treatment • 80% • Blood: 3 pints ‘free’, afterwards covered at 80%

22. Reimbursement for PT services: • Outpatient – Medicare Part B • $1900 cap for non-hospital PT (2013) • On January 1, 2013, Congress passed the American Taxpayer Relief Act of 2012 which extended the Medicare therapy cap exceptions process until December 31, 2013

23. Part B Premium

24. Part B services may be used when • There has been a decline in functional level due to disease, injury, or condition • May or may not have been hospitalized • Not covered currently by Part A services • Decline can be due to: • Pain with decreased functional level, exacerbation of chronic condition with functional decline, exhaustion of Part A services, but still requires further PT services.

25. Medicare payment for home health services • PPS: predesignated payment that varies with health condition & care needs • Agencies provided payment for each 60-day episode of care. • Can have more than one 60 day period • Adjustments are made for significant changes in condition or pts with fewer visits • OASIS if under Part A benefits

26. Quality Measures in Home Health • Improvements in mobility: • Walking or moving around, transfers in/out of bed, less pain while moving around • ADLs • Bladder control, bathing, correct use of meds, dyspnea levels • Long-term outcomes • Patient medical emergencies • Hospital admissions, urgent medical care

27. Managed Care by Medicare • Also called Medicare Advantage Plans • MCOs control access to health care services and create an system that works on efficiency of payment • As with most MCOs bureaucracy results in lapse of time from referral to treatment which impacts outcomes and complicates continuity of care.

28. HMO pros/cons • Pros: • Minimal paperwork • Additional services provided at little to no cost (hearing aids, eyeglasses, dental care) • Cons: • Gatekeeper: limits PT treatments • Specifies which providers can be used • Income received by HMO is on a prepaid basis: so increased incentive to minimize costs.

29. PT Practice Concerns Regarding Medicare • Need to be “enrolled” • Obtain a provider number • Need to accept fee schedule • No waiving copays • Patient may have coordination of benefits with MC primary, other provider secondary

30. In order for Medicare to pay physical therapy services must be: • Reasonable • Necessary • Skilled • Appropriate frequency & duration • Expectation that the condition will improve • Physician must sign the certification every 90 days

31. Medicaid • Differs state by state • Low income (at or below 133% of national poverty level) • May have to ‘spend down’ to be eligible • Spousal Impoverishment Plan: spouse can retain a relatively generous amount of income and assets • Funded by both federal and state levels • Does not pay for MOW, unless pt has a waiver • In some states: PT is an ‘optional’ benefit for Medicaid recipients

32. Medigap insurance policies • Created to gap the payment necessary when part A or B services are not covered. • Usually covers the 20% copayment that A or B does not cover • Expensive • Questionable future due to high costs • Medicare only pays 80% of allowable charges, so many providers charge more than this: leads to need for Medigap or other coverage

33. Veterans Benefits • Veterans Administration (VA) provides a program that covers health care for war veterans through over 153 VA hospitals, 773 outpatient centers and 100 VA nursing homes & contracts with community facilities. • May be able to get specific services • At times wait can be long and distance traveled is great.

34. Other Long Term Care Policies in creation • 35 states are creating their own policies • Hawaii: Family Hope program: program to finance long term care.

35. Medicare Fraud & Abuse • Fraud occurs when someone intentionally falsifies information or deceives the Medicare Program. • Abuse occurs when doctors or suppliers do not follow good medical practices that can result in unnecessary costs to Medicare

36. Medicare and the Future • Pay for Performance- PQRI • Will soon be paid for performance of patients. G-codes. • Accountable Care Organizations • Where department get paid for services • Medical Homes • Cluster of all health care professional that give care to a patient. You can treat in multiple settings. • Annual Wellness Visit • One time a year can see physician for wellness check • BP, Medication, Cognitive loss, functional levels, *need fall risk* • ‘Incident to’ rules: physician referral hand pick patients, not apply to therapy cap.

37. Resources • http://www.cms.gov/ Web page for Centers for Medicare and Medicaid Services (CMS) • www.ssa.gov/OP_Home/ssact/title18/1800.htm • Medicare Act • APTA Government Affairs