PMHNP Boards ALREADY PASSED

Medicare Part A Coverage - Hospital insurance that covers inpatient and most skilled care. Mandatory copays for hospital days 21-150, getting higher with each period of time. Medicare Part A Eligibility - 65 in social security automatic enrollment Medicare Part A Cost - No cost if automatically qualified. 30-39 work quarters: ~$250/mo 30 work quarters: ~$450/mo Medicare Part B Coverage - Supplemental medical insurance. Outpatient services, care, physical/speech therapy, some home health care, medical equipment Medicare Part B Eligibility - Voluntary if 65 Medicare Part B Cost - Deducted from monthly social security check. *Enroll 3 months before 65th birthday or 4 months after, otherwise increased costs to enroll* Medicare Part C - Medicare Advantage. Get all their medical services through that plan. Medicare Part D coverage - Prescription drug coverage Medicare Part D Cost - Varies depending on how extensive drug benefit is. Different plans have different benefits. Medigap Plans - Fill gaps in coverage that occur with Medicare Medicare Advantage Plan - Will likely eliminate need for medigap insurance? Medicaid Eligibility - Automatic coverage not guaranteed except for poor pregnant women and children. States can refuse to cover adults/head of households who lose Temporary Assistance to Needy Families d/t refusal to work. Generally covers poor people. Medicaid funding - Federal + state. States determine how much they want to pay in, different states have different qualities of Medicaid HMO - Four components: Enrolled population, prepayment of premiums, coverage of comprehensive medical svcs, centralization of medical and hospital svcs Closed-panel HMO - Specific providers identified by plan to provide the medical services to members. Staff can be salaried by HMO or an agency/group contracted by the HMO. Open-panel HMO - Network HMO, Individual Practice Association, Point of Service Plans Network HMO - HMO contracts with more than one group of practices Individual Practice Association - Insurance coverage. Contract with an association of physicians to provide services to members Point of Service (POS) and Preferred Provider Organizations (PPOs) - Insurance coverage. Patients allowed to self-refer to specialist but pay higher premium to do so. POS requires PCP is gatekeeper but pt can see a provider outside of HMO for more $$. PPOs contract to a selected group of participating providers and give discount for using a selected group of providers. Financial risk held by insurer in PPO, held by providers in POS Managed indemnity - Traditional model insurance coverage.. Pre-certification, catastrophic case management, minimal contract arrangement with providers. Provider groups and health plans can use quality control, utilization review, bundling of services, incentives for health behaviors. MUST seek National Committee on Quality Assurance (NCQA) accreditation Licensure - Member of profession is granted ability to practice Accreditation - Formal review and approval by a recognized agency of educational degree or certification programs in nursing or nursing-related programs.