CCM-CHAPTER ONE: CARE DELIVERY AND REIMBURSEMENT
METHODS WITH COMPLETE SOLUTIONS 100% 2023/2024
Payer-based Settings, including public health insurance programs
Medicare, Medicaid, and state-funded programs
Payer-based Settings, private health insurance program
Occupational health, disability, group health insurance, managed care organization
Palliative care, home care, and hospice case managers combine the role of caregiver with case
manager. In addition to hands-on nursing responsibilities, they also
1. Liaise with providers, 2. Communicate with treating physicians, 3, Provide patient and family
education, 4. Assess for and coordinate additional services and Durable Medical Equipment, 5.
Provide SN care.
Worker's compensation case management focuses on vocational activities, collaborating with the
employer to get the employee back to work. The case manager will
1. Facilitate communication between the employer, claims adjuster, attorneys, union representative,
state administrative agency,and providers, 2. Coordinate care between multiple healthcare providers,
3. Monitor progress, 4. Utilization review, 5. Obtain precertification when necessary, 6. Perform job
analysis, 7. Accompany injured workers during physician appointments.
Client autonomy
the right of clients to make decisions about their medical care without their case manager trying to
influence the decision. client autonomy does allow for case manager to educate the patient but does
not allow the case manager to make the decision for the client
ADL's measure the level of independence on performing six basic activities
"DEATH" Dressing/bathing, Eating, Ambulating, Toileting, Hygiene. If I can't do these, I would rather
be dead.
The IADLs tool assesses the ability to perform 8 independent living skills that are more complex than
the basic ADLs assessment. These include:
Shopping, Using the telephone, Paying bills/Budgeting, Food preparation, Housekeeping, Laundry,
Using transportation, Handling medications.
Interdisciplinary Care Team (ICT) definition?
is a group of healthcare professionals from various professional disciplines who work together to
manage the physical, psychological, and spiritual needs of the patient may include: physicians, nurses,
case manager, social worker, physical therapist, occupational therapist, chaplain, Dietitian,
Pharmacist.
Accelerated Death Benefit
allowing an insured person with a terminal illness to use some of the policy's benefit prior to dying.
The ADB is deducted from the amount the beneficiaries receive at death. There are restrictions on
how the money can be used; generally it can be used for long-term care and medical expenses.
Viatical Settlements
, A life insurance policy is personal property, meaning it can be sold. A viatical settlement sells the life
insurance policy of a person with a terminal or life-threatening illness, and a life expectancy of less
than five years to a third party for cash. 1. No restrictions on how this money can be used. 2. The
purchasing party then becomes the beneficiary and takes responsibility for paying the premium. 3.
The insured are normally paid 50 and 80% of the face value of the policy. This amount is dependent
on life expectancy, interest rates, and cost of premium. 4. the money is free from federal income tax.
5. earnings may impact eligibility for medicaid.
Reverse Mortgages
for a homeowner and age 62 or older. 1. the patient borrows against his/her home's value without
having to leave the home or make payments. 2. The funds can be distributed by: lump sum/fixed
monthly installments/lines of credit; 3. if use the line of credit is the most popular choices and often
will not be considered an asset for Medicaid eligibility. 4. The amount of money received will be
determined by the home's value, the age of the borrower, and current interest rates; 5. for both
spouses to be listed on the reverse mortgage deed, they must both be 62 or older.
Extra-Contractual Benefits
are benefits not covered under the health plan but are given to the insured due to the cost savings for
the health insurance plan.
Coordination of Benefits (COB) for employee
1. Medicaid always pays last; 2. If an insurance plan does not have a COB provision, it must pay
primary; 3. the longest is primary; 4. The insurance plan covering the client as an employee is the
primary payer over the plan covering as a dependent, which pays secondary; 5. covers an active
employee is primary over a retiree/laid-off employee; 6. covers an active employee is primary over a
COBRA plan which is secondary.
COB for dependents of married parents
the parent whose birthday comes first in the year is primary for the children.
COB for dependents of non-married parents
if both plans cover the client as a dependent, and the parents are not married, primary coverage is
determined by the court. 2. If no court determination has been made, the parent with custody is
primary, followed by the spouse of the parent with custody, and finally the plan of the parents
without custody.
COB for Medicare
1. Age 65 or older and retried, Medicare is primary; 2. Age 65 or older and covered due to the patient
or his spouse working for an employer with 20 or more employee, the employer plan is primary;
3.Age 65 or older and covered due to patient or spouse working for employer with fewer than 20
employees, Medicare is primary.
Disability between Workers' Compensation and STD/LTD
1. Workers' comp provides replacement of lost wages and a medical benefit for the work-related
injury. STD and LTD only cover a portion of the wages, typically 50-70%, and begin after a waiting
period. 2. Workers' comp is mandated to be paid by the employer. LTD and STD can be provided by
employers as part of a benefits package. 3. LTD purchased from an agent is not taxed; whereas LTD as
part of a benefit package is taxed. SSDI is paid for by a tax on the employer and the employee.
METHODS WITH COMPLETE SOLUTIONS 100% 2023/2024
Payer-based Settings, including public health insurance programs
Medicare, Medicaid, and state-funded programs
Payer-based Settings, private health insurance program
Occupational health, disability, group health insurance, managed care organization
Palliative care, home care, and hospice case managers combine the role of caregiver with case
manager. In addition to hands-on nursing responsibilities, they also
1. Liaise with providers, 2. Communicate with treating physicians, 3, Provide patient and family
education, 4. Assess for and coordinate additional services and Durable Medical Equipment, 5.
Provide SN care.
Worker's compensation case management focuses on vocational activities, collaborating with the
employer to get the employee back to work. The case manager will
1. Facilitate communication between the employer, claims adjuster, attorneys, union representative,
state administrative agency,and providers, 2. Coordinate care between multiple healthcare providers,
3. Monitor progress, 4. Utilization review, 5. Obtain precertification when necessary, 6. Perform job
analysis, 7. Accompany injured workers during physician appointments.
Client autonomy
the right of clients to make decisions about their medical care without their case manager trying to
influence the decision. client autonomy does allow for case manager to educate the patient but does
not allow the case manager to make the decision for the client
ADL's measure the level of independence on performing six basic activities
"DEATH" Dressing/bathing, Eating, Ambulating, Toileting, Hygiene. If I can't do these, I would rather
be dead.
The IADLs tool assesses the ability to perform 8 independent living skills that are more complex than
the basic ADLs assessment. These include:
Shopping, Using the telephone, Paying bills/Budgeting, Food preparation, Housekeeping, Laundry,
Using transportation, Handling medications.
Interdisciplinary Care Team (ICT) definition?
is a group of healthcare professionals from various professional disciplines who work together to
manage the physical, psychological, and spiritual needs of the patient may include: physicians, nurses,
case manager, social worker, physical therapist, occupational therapist, chaplain, Dietitian,
Pharmacist.
Accelerated Death Benefit
allowing an insured person with a terminal illness to use some of the policy's benefit prior to dying.
The ADB is deducted from the amount the beneficiaries receive at death. There are restrictions on
how the money can be used; generally it can be used for long-term care and medical expenses.
Viatical Settlements
, A life insurance policy is personal property, meaning it can be sold. A viatical settlement sells the life
insurance policy of a person with a terminal or life-threatening illness, and a life expectancy of less
than five years to a third party for cash. 1. No restrictions on how this money can be used. 2. The
purchasing party then becomes the beneficiary and takes responsibility for paying the premium. 3.
The insured are normally paid 50 and 80% of the face value of the policy. This amount is dependent
on life expectancy, interest rates, and cost of premium. 4. the money is free from federal income tax.
5. earnings may impact eligibility for medicaid.
Reverse Mortgages
for a homeowner and age 62 or older. 1. the patient borrows against his/her home's value without
having to leave the home or make payments. 2. The funds can be distributed by: lump sum/fixed
monthly installments/lines of credit; 3. if use the line of credit is the most popular choices and often
will not be considered an asset for Medicaid eligibility. 4. The amount of money received will be
determined by the home's value, the age of the borrower, and current interest rates; 5. for both
spouses to be listed on the reverse mortgage deed, they must both be 62 or older.
Extra-Contractual Benefits
are benefits not covered under the health plan but are given to the insured due to the cost savings for
the health insurance plan.
Coordination of Benefits (COB) for employee
1. Medicaid always pays last; 2. If an insurance plan does not have a COB provision, it must pay
primary; 3. the longest is primary; 4. The insurance plan covering the client as an employee is the
primary payer over the plan covering as a dependent, which pays secondary; 5. covers an active
employee is primary over a retiree/laid-off employee; 6. covers an active employee is primary over a
COBRA plan which is secondary.
COB for dependents of married parents
the parent whose birthday comes first in the year is primary for the children.
COB for dependents of non-married parents
if both plans cover the client as a dependent, and the parents are not married, primary coverage is
determined by the court. 2. If no court determination has been made, the parent with custody is
primary, followed by the spouse of the parent with custody, and finally the plan of the parents
without custody.
COB for Medicare
1. Age 65 or older and retried, Medicare is primary; 2. Age 65 or older and covered due to the patient
or his spouse working for an employer with 20 or more employee, the employer plan is primary;
3.Age 65 or older and covered due to patient or spouse working for employer with fewer than 20
employees, Medicare is primary.
Disability between Workers' Compensation and STD/LTD
1. Workers' comp provides replacement of lost wages and a medical benefit for the work-related
injury. STD and LTD only cover a portion of the wages, typically 50-70%, and begin after a waiting
period. 2. Workers' comp is mandated to be paid by the employer. LTD and STD can be provided by
employers as part of a benefits package. 3. LTD purchased from an agent is not taxed; whereas LTD as
part of a benefit package is taxed. SSDI is paid for by a tax on the employer and the employee.
