Medicare Basics
What is Medicare?
A federal health insurance program primarily for people age 65 and older, as well as some younger individuals with qualifying disabilities
What is Medicaid?
A joint federal and state insurance program for individuals that make below a certain income, as well as for individuals with disabilities or chronic conditions
What is private insurance?
Health insurance provided by non-government companies
What does "reimbursement" mean?
Payment for services provided.
True or false. Insurance reimbursement influences how often and how long OT services are provided.
True
Which part of Medicare typically covers outpatient services?
Medicare Part B
True or false. Medicaid coverage is identical across all states?
False. (Each state runs its own Medicaid program)
True or False. All private insurance plans cover OT services the same way.
False
This term means services must be reasonable and necessary for the patient's condition.
Medical necessity
An OT spends extra time making sure goals are functional and measurable. Why?
Insurance requires clear documentation to support reimbursement
Which part of Medicare usually covers inpatient hospital stays and SNF care?
Medicare Part A
True. OT is recognized as an optional covered service under Medicaid
Prior authorization
What is "documentation"?
Written records that justify OT services and support reimbursement
True or false. Understanding reimbursement is only the responsibility of billing staff, not OTs.
False
True or False. Medicare coverage rules are the same in every state?
Why should OTs understand their state's Medicaid rules?
Coverage, service limits, and reimbursement vary by state
Why might private insurance plans be challenging for OTs to navigate?
Each plan has different rules, coverage limits, and documentation requirements
This term refers to the maximum number of OT visits an insurance plan will pay for.
Visit limit or therapy cap
Why might an OT adjust treatment frequency based on insurance type?
Different payers have different coverage limits and reimbursement rules
What is one reason that documentation is especially important when treating Medicare clients?
Medicare requires proof of medical necessity to justify OT services and reimbursement
Medicaid often plays a critical role in OT services for which population?
Children and individuals with disabilities or low income.
What is a common reason that an OT claim might be denied by private insurance?
Lack of medical necessity, missing documentation, or services not covered under the plan
Why is reimbursement knowledge considered an ethical responsibility for OTs?
It helps ensure services are provided legally, appropriately, and sustainably.
An OT wants to run a community fall-prevention group, but insurance won't reimburse group services. What is one realistic way that this program might still be offered?
Through grants, community funding, private pay, or partnerships with local organizations