Medicare Past Paper 2021 PDF

CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The need for diversity in the nursing workforce The need for better data to evaluate progress Healthy People 2030 n...

CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The need for diversity in the nursing workforce The need for better data to evaluate progress Healthy People 2030 needs a lot of work Primary care is defined as: continuous, person centered, relationship based care that considers the needs and preferences of individuals, families, and communities Core competencies for APRNS: Domain 1: Knowledge for Nursing Practice Domain 2: Person-Centered Care Domain 3: Population Health Domain 4: Scholarship for Nursing Practice Domain 5: Quality and Safety Domain 6: Interprofessional Partnerships Domain 7: Systems-Based Practice Domain 8: Information and Healthcare Technologies Domain 9: Professionalism Domain 10: Personal, Professional, and Leadership Development CHAPTER TWO: The APRN role is grounded in the knowledge of skills and caring CARING The intentional and authentic presence of the nurse with another person who is living, caring. In nursing, caring directly characterizes a nurse's knowledge base and service. Generalized patterns of nursing care are represented in the CIRCLE OF CARING MODEL: Courage Authentic presence Advocacy Knowing Commitment Patience CHAPTER FIVE Elements of the diagnostic process: Onset -- duration, characteristics Location -- aggravating factors, relieving factors, treatment Medicare is a health insurance program for people 65 and older that has four parts: Part A, Part B, Part C, and Part D:  - - - - Medicare A---Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP's scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was \$1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: \$371 per day coinsurance Days 91 and beyond: \$742 coinsurance per "lifetime reserved day" used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a \$185.50 per day copayment---days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B---Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule \[PFS\]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in "better accessibility, quality, affordability, empowerment, and innovation" (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician's fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from \$50 to \$300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was \$203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient's payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D---Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was \$4,120, up from \$4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached \$6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan's payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program's financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children's Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). **Health Insurance Portability and Accountability Act (HIPAA)** HIPAA can mean different policy concerns to different people. The act is separated into two parts, Title I and Title II: Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II addresses administrative simplification and requires the U.S. Department of Health and Human Services to establish national standards for electronic health-care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. These standards were implemented to improve the efficiency and effectiveness of the nation's health-care system by encouraging the widespread use of electronic data interchange in health care (CMS, 2005). HIPAA legislation is important to the daily management of the practitioner practice setting. This legislation focuses on password management, workstation security, e-mail and Internet use, and facility/physical security. Password protection ensures the privacy of patients' health-care information. With increased mandatory submission of electronic billing files and EMRs, a provider must take added precautions to protect the patient's electronic personal information **PRIMARY PREVENTION**: Immunizations, health education, skin cancer prevention methods, weight control, seat belt use, education on: smoking, alcohol, drugs, protective hearing, nutrition, exercise, stress reduction **SECONDARY PREVENTION:** Screenings -- cancers, diabetes, hypertension, stds, anemia, height, weight, BMI screenings **TERIARY PREVENTION:** Treatment to prevent further sequelae of cardiovascular disease, respiratory disease, etc **Primary, secondary, and tertiary prevention are three levels of health promotion and disease prevention**:  - - - - - - - - - - - - - - POWERPOINT NOTES **PRIMARY CARE IN THE 21^st^ CENTURY - A CIRCLE OF CARING** Florence Nightengale -- 1861, laws of sickness and laws of health Lavinia Dock -- evolved a community health nursing model at beg of 20^th^ century Virginia Henderson -heart, head, hand of nursing -- health happens where people live, love, learn, work, play Standardized nursing protocols -- evolved from the work of early school nurses and NY public health department Martha Rogers -argued for necessity of independent basis of nursing practice where autonomous nursing practice could grow 1990 -- Benners "from novice to expert" used by NONPF to create 5 domains for framwork for primary care NP curricula **2006 -- revised NONPF** -- ***7 domains*** and 75 core competencies that NPs must demonstrate upon graduation: Management of patient health/illness status Teaching/coaching function NP patient relationship Professional role Managing and negotiating health-care delivery systems Monitoring and ensuring the quality of healthcare practice Culturally sensitive care **Swanson**: 1995 Spirit function conceptual model of nursing for the APRN The core of every person is the spirit -- the spirit is an animating or vital principle held to give live to physical organisms **Nursing** is a goal directed interpersonal relationship between the patient and nurse, based on traditional nursing process components such as assessing, planning, intervening, and evaluating Interventions are broad based and range from play, music, and stories to the utilization of counseling principles such as active listening and anticipatory guidance **Shuler's 1993 NP practice model:** Rooted in holistic patient database that includes physical, social, cultural, environmental, and spiritual dimensions The patient's physical and psychological ability to participate in wellness activities is assessed and creative, uninhibited problem-solving and identification of appropriate wellness activities are pursued **Symptom Management 1994:** Symptoms should be reviewed as subjective experiences reflecting changes in a person\'s biophysical function, sensation, or cognition. 3 dimensions The symptom experience (subjective) Symptom management strategies Symptom outcomes **Snyder and Mirr 1995:** Conceptualize advanced practice within a nursing paradigm around human responses as a focus for nursing interventions Self-care limitations Impaired functioning in areas of rest, sleep, ventilation, circulation, nutrition Pain and discomfort Emotional problems related to the illness and treatment, life-threatening events, or daily experiences like anxiety, loss, or loneliness Distortion of symbolic functions reflected in interpersonal and intellectual processes such as hallucinations Deficiencies in decision-making ability to make personal choices Self-image changes required by health status Dysfunctional perceptual orientations to health Strains related to life processes such as birth, development, and death Problematic affiliative relationships **Ryan's 2009 Integrated Theory of Health Behavior Change (ITBHC):** Health promotion activities are an integral part of the long-term health and well-being of both healthy people and those with chronic illnesses APNs are in a position to facilitate and support health behavior changes in their clients and can tailor interventions that can positively affect long-term health status **Cumbie, Conley, and Burman's 2004 model of promoting process engagement:** Client centered theory developed to help APNs managed the care of chronically ill clients Interventions of the APRN are chosen based on each client\'s needs and expectations of their care, are developed in collaboration with the client **Nurse coaching:** Promotes integrative approaches for health and wellbeing Can be used to promote behavioral change Uses motivational interviewing, nonjudgemental acceptance of the patient, the transtheoretical model of behavioral change, appreciative inquiry, cultural perspectives, and "rituals of healing" **Changing Models of Medical Practice and Research:** Contributing factors to re-examination of traditional professional roles Advances in therapeutics, progress of medicine from integrated view of illness and therapeutics to one of discrete diseases with distinct causes and specific therapeutics - Success of this led to physician specialists with narrow focus on human disease and to technologically advanced medical interventions that are removed from day to day lives of patients Some difficulties fulfilling moral and social responsibilities of medicine, realization of limits of medical progress and technological intervention Call for a better balance between cure-oriented and care-oriented medicine **The Circle of Caring:** Broadened and contextualized database, labeling of the patient's concern that incorporates the patient\'s responses to the meaning of illness in his/her day-to-day life Holistic approach to an individualized therapeutic plan that includes nursing interventions based on evidence which can include complementary therapies incorporated with surgical, pharmacologic, and non-pharmacologic interventions The outcomes are viewed based on the patient, family, group, and community perceptions of improvement, as well as the more traditional, quantified outcome measures like mortality and morbidity data This model is a synthesized view of a problem solving methodology for a variety of settings. It is a contextualized approach The phenomenon of human responses as "calls for nursing" This is the HALLMARK of broadened approach to therapeutics and interventions Caring is the CENTRAL concept in nursing and is uniquely known and expressed in nursing, nursing takes place within nursing situations, nursing is a discipline of knowledge and a professional service that's goal is nurturing persons living, caring, and growing in caring Attributes of caring: knowing, patience, authentic presence, commitment, courage, and advocacy Productive tension between healthcare professionals benefits the care of all patients **CARING AND THE ADVANCED PRACTICE NURSE:** Caring is the essence of being human, caring is the essence of nursing ALL human based services are based on caring; nursing is DIFFERENT because caring directly characterizes nursing's knowledge base and services **Medicine** -- in medicine, a fundamental commitment to caring is directing characterized in the DX and RX of human structural and functional problems, usually characterized in physical terms **Generalized patterns of caring**: ***Courage*** -- the human act, daily application of values, ethical grounding for practice, manifests itself in making one's nursing vocation on commitment to these values and beliefs that undergird caring **Authentic presence:** Intentionally being with another in the fullness of ones personhood. The caring initiated through authentic presence is the initiating and sustaining medium of nursing within the nursing situation **Advocacy:** GADOW-EXISTENTIAL ADVOCACY -- self is brought into the situation as a full partner. When the nurse offers existential advocacy, the nurse feels known, respected, and connected in a way that affirms humanity and being **Knowing:** Directly implies being deeply attuned, comes through intentional and authentic presence. There are patterns of knowing: Practitioner draws on personal knowing as essential intuitive knowing Empiric knowing -- avenue for drawing on science and skilled observation Ethical knowing -- prompts consideration of values and morals for situations Esthetic knowing -- incorporation of knowing into a situation for integrated understanding with the nursed **Commitment:** Choosing to be a member of the discipline and profession of nursing speaks to a lifelong commitment of service to humankind Directs obligation or what "ought to be" in a particular situation Conflicts to commitment -- economically driven care might conflict with calls from patients **Patience:** Trusting people to grow at their own pace, in their own way Not a passive attribute -- an active openness to "the moment alive with possibilities" Humility and courage intimately linked to patience -- the courage to let someone "be" and freedom of choice **ELEMENTS OF THE DIAGNOSTIC PROCESS:** **OLD CART** Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment