Key Terms + Medicare and Medicaid

Key Terms: Standard of Care

• There is no medical definition of “standard of care”

• This term is commonly used in medical situations to refer to a diagnostic and treatment process that a prudent health care provider ought to follow for a certain type of patient, illness or clinical circumstance or in legal terms “the degree to of care that a reasonable person should exercise”

• Thus → standard of care is the acceptable and appropriate care that
  an occupational therapist provides for a client’s condition

Key Terms: Informed Consent

• Respect for a client’s autonomy by allowing the client to be the master of their own course of intervention and provides control in what the client may experience as an upsetting, out-of-control situation

• Considerations

  • Health literacy

  • Cognition

Public Policy and Healthcare

• Policy reflects society’s values and beliefs

• In most developed countries, there is some form of universal health coverage

• In the United States the three laws most salient to the health of older adults are:

  • Medicare

  • Medicaid

  • Older Americans Act

Medicare

• Enacted 1965

• Paid in part by worker/employer contributions, in part by insurance-type premiums

• Universal coverage for those over 65 and for individuals with disabilities

  • Part A: Hospitalization, skilled nursing home care, home health care, and hospice

  • Part B: Physician and other health provider

  • Part C: Medicare advantage plans

  • Part D: Prescription medication

Medicare Coverage

• The largest single payer of health care services in the United States

• Influences provisions of other insurance plans because of its size and scope

• Eligibility for coverage

  • At least 65

  • Have been a U.S. citizen or permanent resident for a least 10 years

  • Paid (or had a spouse who paid) Medicare taxes for at least 40 years OR

  • Permanently disabled (even if not 65)

Medicare and Therapy

• Medicare is the primary source of payment for older adults

• Items in parts A, B, and C are relevant to OT/PT and other therapy coverage

Medicare Part A

• To be eligible for coverage, a person must

  • Be at least 65 years of age

  • Have been a US citizen or permanent resident for at least 10 years

  • Paid (or had a spouse who paid) Medicare taxes for at least 40 quarters

• Individuals under 65 are eligible if they are permanently disabled, received social security disability payments for at least the previous 2 years, receive Social Security disability benefits for ALS, or need continuous dialysis or a kidney transplant

• Beneficiary will have experienced an acute medical crisis requiring hospitalization, followed by a lesser level of inpatient care in a Skilled Nursing Facility (SNF)

• Hospital benefits cover acute illnesses, diseases, or surgical care, typically for just a few days

• Hospital and SNF benefits include room and board and medically necessary professional services such as therapy services that must meet program requirements

• When the beneficiary no longer needs the services provided in the hospital, reaches goals specific to the care setting, or has exhausted their benefits, additional therapy and services can then be provided in the home

• Co-pays and other out-of-pocket expenses are part of the plan

• Hospice care covered completely

• SNF covered for up to 100 days for rehabilitation

  • Therapy services are included and help determine level of reimbursement

Medicare Part B

• Covers diagnostic, therapeutic, and preventive medical services; health-
  related professional services, durable medical equipment, prosthetics,
  and orthotics

• Beneficiaries pay roughly 25% of costs

• Covers the services by independent occupational therapists, physical therapists, and speech language pathologists as well as outpatient therapy services in hospitals, SNFs, rehabilitation agency, doctor’s office, therapist’s office, Comprehensive Outpatient Rehabilitation Facility (CORF), or home, with a home health agency or therapist in private practice

Jimmo vs. Sebelius (2013)

• Changed eligibility for Medicare services

• Previously, progress/improvement was required for skilled nursing home and home health care

• Findings in this action changed this so that functional maintenance and delayed decline as outcomes are covered (i.e., not necessarily dependent on progress/improvement)

Medicaid

• Enacted 1966

• Coverage for indigent individuals of any age

• Also covers some long-term care for older adults

• Joint federal-state program

  • Since programs vary from state to state, criteria are complicated

• Individuals need to satisfy federal and state requirements regarding residency, immigration status, or U.S. citizenship

• Moving toward HMO type plans (away from fee-for-service)

  • Health Maintenance Organization plans- type of health insurance typically offering lower premiums but restricts coverage to a network of doctors and hospitals

• Concern for spouse remaining in community because of spend-down provisions (if all of their funds are tied together)

Medicaid Qualifications

• Individuals need to satisfy federal and state requirements regarding residency, immigration status, documentation of U.S. citizenship, and income

• Long-term care coverage is available only to those who have no financial resource

  • Recipients with assets are required to spend them down to
    become eligible