Overview of Medicare and Medicaid Programs, Exams of Survey Sampling Techniques

Download Overview of Medicare and Medicaid Programs and more Exams Survey Sampling Techniques in PDF only on Docsity! DO NOT COPY SMQT- Survey & Certification Background Questions (Latest 2023-2024) 1. Social Security Act of 1965 - correct answer ✅It was signed into law by President Johnson on July 30, 1965. The law established both Medicare, the health insurance program for Americans over 65 and Medicaid, the health insurance program for low- income Americans. 2. Health Care Financing Administration (HCFA) - correct answer ✅Created in 1977 to combine, under one administration, the oversight of Medicare and Medicaid under the HCFA (the predecessor of CMS). 3. Medicare - correct answer ✅Signed into law in 1965, Medicare is a Health Insurance Program for the following groups: - People age 65 or older - People under age 65 with certain disabilities - People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) 4. Medicaid - correct answer ✅Medicaid is a medical assistance program jointly financed by State and Federal governments for eligible low-income individuals. The program covers a variety of groups, including the following: - The needy elderly - Blind - Disabled individuals receiving cash assistance under the Supplemental Security Income Program - Certain infants and low-income pregnant women - At the option of the State, other low-income individuals with medical bills that qualify them as categorically or medically needy. 5. Medicaid is a state program that provides medical services to clients of the state public assistance program and, at the State's option, other needy individuals. 6. Medicaid also augments the hospital and nursing facility (NF) services mandated under Medicaid. 7. States may decide on the amount, duration, and scope of additional services, except that care in institutions primarily for the care and treatment of mental health issues, may not be included for persons over age 21 and under age 65. P a g e 1 | 19 8. Clinical Laboratory Improvement Amendments (CLIA) - correct answer ✅Signed into law in 1988, CLIA regulations include federal standards applicable to all U.S. laboratory facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CDC, in partnership with the CMS and FDA, supports the CLIA program and clinical laboratory quality. - The Centers for Disease Control & Prevention is responsible for the CLIA studies, convening the Clinical Laboratory Improvement Amendments Committee (CLIAC) & provides scientific & technical support to CMS. - A laboratory is defined as any facility that performs laboratory testing on specimens derived from humans for the purpose of providing information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health. - CLIA covers approximately 175,000 laboratory entities. - The Food & Drug Administration (FDA) is responsible for test categorization. - The Division of Laboratory Services, within the Survey & Certification Group, under the Center for Medicaid, CHIP and Survey & Certification have the responsibility for implementing the CLIA Program. - CMS is charged with the implementation of CLIA, including laboratory registration, fee collection, certificate generation, surveys, surveyor guidelines development & training, enforcement, financial management, & finally, approvals of proficiency testing providers, accrediting organizations & exempt states. 9. Title XVIII of the Social Security Act - correct answer ✅Title XVIII (18) established regulations for the Medicare program. The Chapter also provides insurance coverage for P a g e 2 | 19 - Records & Reports 23. State Agency function-- Title XVIII, Section 1864(a): Identifying Prospective Payment System (PPS) excluded institutions - correct answer ✅Certification information helps in identifying institutions or components of institutions that meet special requirements that qualify them to be excluded from the Medicare PPS. 24. State Agency function-- Title XVIII, Section 1864(a): Participating on validation surveys of accredited entities - correct answer ✅Ensures validation surveys of accredited entities; surveys furnish DHHS and Congress with a monitoring ability of CoPs. Surveys establish the validity of "deeming" that accredited entities meet the CoPs. 25. State Agency function-- Title XVIII, Section 1864(a): Monitoring proficiency testing - correct answer ✅This function allows state agencies to monitor programs of proficiency testing in laboratories and contribute laboratory compliance findings for use in the CLIA Laboratory Certification Program. 26. State Agency function-- Title XVIII, Section 1864(a): Directing data entry - correct answer ✅State agencies are responsible for entering data from surveys, conducting follow-up visits, and conducting complaint investigations into the OSCAR/ODIE system- the national mainframe computer system that is used for maintaining & retrieving certification data. 27. State agencies are also responsible for updating information about providers, suppliers, and CLIA laboratories in the system when indicated. 28. OSCAR/ODIE System - correct answer ✅Online Survey Certification and Reporting System (OSCAR) 29. Online Data Input and Edit (ODIE) 30. ODIE is a subsystem of the Online Survey Certification & Reporting (OSCAR) system, which is a database & retrieval program P a g e 5 | 19 31. OSCAR and ODIE are the original system name under the CLIA data system. The most current release is known as the Automated Survey Processing Environment/Quality Information Enterprise System (ASPEN/QIES) for CLIA. 32. State Agency function-- Title XVIII, Section 1864(a): NURSE AID TRAINING - correct answer ✅State agencies are required to specify, review, and certify Nurse Aide Training and Competency Evaluation Programs (NATCEPs). 33. NATCEP - correct answer ✅Nurse Aide Training and Competency Evaluation Program 34. State Agency function-- Title XVIII, Section 1864(a): Nurse Aide Registry - correct answer ✅The Nurse Aid Registry is a listing of nurse aides who have met Federal and state training and competency requirements necessary for employment in nursing homes. 35. All state agencies are required to establish and maintain a registry for all individuals who have satisfactorily completed Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Nurse Aide Competency Evaluation Program (NACEP). 36. References: - SOM Ch. 4, §4145 - SSA 1819 (e)(2) - SSA 1919(e)(2) 37. State Agency function-- Title XVIII, Section 1864(a): Resident Assessment Instrument (RAI) - correct answer ✅State agencies are required to specify a RESIDENT ASSESSMENT INSTRUMENT (RAI) for use in the LTC facilities participating in Medicare and Medicaid. 38. REFERENCE: - SOM Chapter 4, 4145.4 P a g e 6 | 19 39. State Agency function-- Title XVIII, Section 1864(a): Records & Reports - correct answer ✅State agencies must maintain pertinent survey, certification, statistical, and other records for a period of at least FOUR years 40. State agencies must make reports in the form and content as the Secretary may require. 41. Title XIX (19) of the Social Security Act, Section 1902(a)(9)(A) - MEDICAID - correct answer ✅Requires that a State use this same agency to set and maintain additional standards for the State Medicaid program. 42. Title XIX (19) of the Social Security Act, Section 1902(a)(33)(B) - correct answer ✅This section of the SSA requires the state to use the same agency utilized for Medicare. 43. If such agency is not the state agency responsible for licensing health institutions, it requires the state to use the agency responsible for such licensing in order to determine whether institutions meet all applicable Federal health standards for Medicaid participation. 44. Licensing under this section is subject to validation by the Secretary. 45. Chapter 1865 of SSA establishes five different nationally approved accreditation organizations. List them: - correct answer ✅1) The Joint Commission (TJC) 46. 2) American Osteopathic Association (AOA) 47. 3) Community Health Accreditation Program (CHAP) 48. 4) Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC) 49. 5) American Association for Accreditation for Ambulatory Surgery Facilities (AAAASF) P a g e 7 | 19 65. ***The state agency is responsible for determining whether the facility meets Medicaid certification requirements.*** 66. The state agency may accept Medicare certification as sufficient evidence of meeting Medicaid requirements, or the state agency may conduct a survey. 67. The Indian health tribal facilities are not considered to be Federal providers and are surveyed by the STATE AGENCY. 68. Additional exceptions to State Agency certification (2 of 2) - correct answer ✅Section 1861(e) of the Act includes in the definition of "hospital," a Christian Science Sanatorium that is operated or listed and certified by the First Church of Christ Scientist, based out of Boston, Massachusetts. 69. Section 1861(e) also deals with respect to certain items and hospital services furnished to inpatients. 70. Section 1861(y) includes sanatoria with respect to items and services furnished to inpatients in a long-term care setting. 71. All approvals are handled by the Boston RO (CMS). 72. ***No state agency certifications are necessary. The State may also include these services under the State plan for Medicaid.*** 73. Exemption of Laboratories Licensed by States - correct answer ✅CLIA will exempt laboratories in States that have been determined to have laws and regulations in effect that are equal to or more stringent than CLIA requirements. P a g e 10 | 19 74. Exempt laboratories must hold a valid State license within the exempt State. 75. 42 CFR Part 488.6----- Eligibility for Medicaid Facilities - correct answer ✅Eligibility for Medicaid participation can be established through Medicare deemed status for providers and suppliers that are not required under Medicaid regulations to comply with any requirements other than Medicare participation requirements for that provider or supplier type. 76. See 42 CFR Part 488.6. 77. SOM, Ch. 6 78. CLIA Laboratories - correct answer ✅Each accrediting organization that has received deeming authority (under CLIA) is approved for specific laboratory specialties / subspecialties. 79. Refer to Chapter 6 of the State Operations Manual (SOM) for additional information on accrediting organizations. 80. CLIA Laboratories approved for distinct specialties and subspecialties: - correct answer ✅- American Association of Blood Banks - American Osteopathy Association - American Society of Histocompatibility & Immunogenetics - The Joint Commission - College of American Pathologists P a g e 11 | 19 - Commission on Office Laboratory Accreditation 81. CERTIFICATION - correct answer ✅Certification is a recommendation made by the State Agency (SA) on the compliance of providers and suppliers with the conditions of participation, requirements, and conditions of coverage. 82. State Agencies officially certify the findings that health care entities do the following: - Meet the Act's provider or supplier definitions - Comply with standards required by Federal regulations 83. CMS Headquarters - correct answer ✅- Located in Baltimore, MD - Overall policy-making responsibility is centralized at CMS Baltimore headquarters - In Baltimore HQ, all aspects of the Medicare program and oversight of the State Medicaid programs are coordinated - Monitoring, surveillance, & overall administrative control of the certification process including its financial aspects - Establishing operational policy for the certification process - Conveying operational instructions and official interpretations of policy to the State Agencies (SA) and the CMS regional offices (ROs) P a g e 12 | 19 - Helping to eliminate discrimination based on health status for people buying health insurance 90. QUIZ QUESTIONS: 91. Select ALL the statements about the 1864 Agreement with States that are TRUE: - correct answer ✅ANSWERS: 92. The Governors of each state designate SAs; 93. the lifetime of the agreements is unlimited; 94. the State Agencies must keep the necessary and appropriate records to be furnished as required by delegates of the Secretary; 95. the Federal Government provides the funds for the costs of performing the functions authorized by the agreements. 96. QUIZ QUESTION: 97. Which of the following functions do the SAs perform under the agreements in §1864 of the Act? - correct answer ✅ANSWER: 98. Under the agreements in §1864 of the Act: - State Agencies explain the requirements to providers and potential providers; - Operate Toll-Free Home Health Hotline; - Certify and Re-certify; - Identify potential participants; - Conduct investigations and fact-finding surveys 99. QUIZ QUESTION: 100. Which of the following are nationally approved accreditation organizations under §1865 of the Act? - correct answer ✅ANSWER: 101. There are five nationally approved accreditation organizations under §1865 of the Act. They are as follows: - The American Association for Accreditation for Ambulatory Surgery Facilities (AAAASF); - The American Osteopathic Association (AOA); P a g e 15 | 19 - The Community Health Accreditation Program (CHAP); - The Joint Commission (TJC); and the Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC). 102. QUIZ QUESTIONS: 103. ALL of the statements are TRUE - correct answer ✅ANSWER: 104. The following statements are true about certification: - State Agencies officially certify their findings as to whether health care entities meet the Act's provider or supplier definitions; - State Agencies officially certify their findings as to whether the entities comply with standards required by Federal regulations; - A facility must be in operation to obtain Federal certification. 105. QUIZ QUESTION: 106. The date of compliance is based on which three requirements? - correct answer ✅ANSWER: 107. The date of compliance is based on the following: - Compliance with all applicable Conditions of Participation (CoP) - Substantial compliance with the requirements for SNFs & NFs P a g e 16 | 19 - Compliance with applicable Conditions for Coverage for suppliers. 108. QUIZ QUESTION: 109. How are Federal regulations are developed? - correct answer ✅ANSWER: 110. CMS analysts and lawyers review the law and conference report; then CMS drafts a proposed rule. The Rule is published in the Federal Register and the public may comment during the comment period (usually 60 days). CMS analysts & lawyers review all of the public comments received. Any suggested changes that will improve the quality of the regulation are incorporated. The final rule is published in the Federal Register. 111. QUIZ QUESTION: 112. What purpose is served by a review of the Conference Report? - correct answer ✅ANSWER: 113. The Conference Report contains how the law was introduced and may contain detailed information that sheds light on the legislator's intent. 114. QUIZ QUESTION: 115. How often are final rules published in the Federal Register incorporated into the Code of Federal Regulations? - correct answer ✅ANSWER: 116. The final rules published in the Federal Register are incorporated into the Code of Federal Regulations once a year. 117. QUIZ QUESTION: 118. Why is the survey and certification process necessary? - correct answer ✅ANSWER: 119. The survey and certification process is necessary because of the following reasons: P a g e 17 | 19