Questions and Answers
National Health Coverage for an American 65 years and older known as Medicare was signed into legislation by who?
Lyndon B. Johnson
What is the federal agency that is responsible for implementation of all rules, regulations and health related policies governing the Medicare program?
Centers for Medicare/ Medicaid Services (CMS)
What is Medicare?
Federal Health Insurance Program
A program of income support for low-income aged, blind, and disabled persons is called?
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For an illegal immigrant to be eligible for benefits under the Medicare program they must have lived in the United States as a permanent resident for 5 consecutive years.
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Medicare identification cards are currently being shifted from Social Security Numbers to Medicare Beneficiaries Identifiers Numbers or MBI effective from ___________.
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A short term inpatient stay that is necessary for a terminally ill patient to give temporarily leave to the person who regularly assists with home care is referred to as?
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The frequency of Pap tests that may be billed for a Medicare patient who is low risk is?
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Plans may be offered under a Medicare advantage plan include?
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Some Medicare Advantage plans may provide services not covered by Medicare such as?
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Medi-gap insurance may cover?
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A program that contracts with CMS to review medical necessity and appropriateness of inpatient medical care is known as?
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A participating physician with a Medicare plan agrees to accept what percent of what?
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In the Medicare program, there is mandatory assignment for?
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When a Medicare patient signs an advance beneficiary notice or an ABN, the procedure code for the service provided must be modified using the HCPCS Level II modifier?
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A Medicare prepayment screen?
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Under the prospective payment system (PPS), hospitals treating Medicare patients are reimbursed according to?
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A type of value-based program established by Medicare to provide an incentive for hospitals to reduce hospital-acquired conditions by reducing payments of the worst-performing hospitals is called?
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An example of an advanced alternative payment model is?
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Immediately enforced system of Health Insurance that insures a country's population against the cost of health care is ___________ Health Insurance.
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Medicare provides insurance for people ______ years of age or older, who are retired on social security.
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An organization that provides pain relief, symptom management and supportive services to terminally ill people and their families should submit claims to Medicare Part ___
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End-Stage Renal Disease occurs when a patient who has chronic kidney disease has gradual loss of kidney function and reaches a _____________ state.
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Patients who are entitled to receive benefits are referred to as _______________
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Medical beneficiary identifiers, which will be used for claims submission purposes are ________ characters in length in only numbers and uppercase letters.
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A Medicare ___________ period begins on the day the patient enters a hospital and ends when the patient is not a bed patient in any hospital or nursing facility for 60 consecutive days.
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Medicare Part B covers medical services and supplies that are _________ to the patient's health conditions.
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Under Medicare Part B dental care is covered only for __________ or surgery of the jaw.
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Medicare advantage plans receive a ____________ amount of money from Medicare to spend on their Medicare members.
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In a Medicare/Medical Savings Account (MSA) the patient uses the MSA money to pay medical expenses until a high deductible is reached; if the MSA money becomes depleted the patient must pay ________ until the deductible is reached.
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Medicare Part ___ offers seniors and people living with disabilities a prescription drug benefit.
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The temporary limit on what the Medicare drug plan will cover for drugs is referred to as a ___________.
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The list of covered drugs that each Medicare drug plan has is referred to as a ___________.
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After a railroad Medicare claim has been processed a ________ document is generated to the service provider explaining the decision made on the claim.
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A specialized insurance policy that is predefined by the federal government for the Medicare beneficiary to cover the deductible and copayment amounts is referred to as _________
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Every Medi-gap policy must follow federal and state laws and must be clearly identified as a Medicare _____________ Insurance.
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MSP rules state that Medicare is the secondary payer when an aged worker has benefits under a group health plan with more than ________ covered employees.
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A Medicare nonparticipating physician may bill no more than the Medicare ___________.
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What does NPI stand for?
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Medicare provides insurance for disabled individuals if they have received social security disability benefits for 24 months.
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All persons age 65 who meet eligibility requirements for Medicare receive Medicare Part B.
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Medicare provides insurance for disabled workers of any age.
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Patients who elect Medicare Part B Coverage pay annually increasing basic premium payments.
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It is possible for an alien to be eligible for Medicare Part A and Part B.
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Employee and employer contributions help pay for Medicare Part A health services.
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Each Medicare hospital benefit period consists of 60 consecutive days in a hospital or nursing facility.
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The number of Medicare benefit periods a patient can have in the hospital care is limited.
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Medicare Part B comes equally from those who sign up for it and the federal government.
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In the Medicare program, a physical examination is a covered benefit when performed within 12 months of enrollment.
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A Medicare patient with a Medicare Advantage plan does not need a supplemental insurance policy.
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When a Medicare recipient chooses a Medicare Senior plan, he or she forfeits the Medicare card.
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Nonparticipating physicians have an option regarding accepting assignment on the Medicare patient.
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A nonparticipating physician who is not accepting assignment may bill any fee he or she wants.
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The time limit for sending in Medicare claims is the end of the calendar year in which professional services were performed.
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Study Notes
Medicare Overview
- Medicare is a federal health insurance program for Americans aged 65 and older, as well as for certain younger individuals with disabilities or specific conditions.
- Signed into law by President Lyndon B. Johnson.
Administration
- The Centers for Medicare & Medicaid Services (CMS) oversees the Medicare program.
Medicare Parts
- Part A: Covers hospice care and inpatient hospital stays.
- Part B: Provides coverage for medically necessary services and supplies, with specific limitations on dental care.
- Part D: Offers prescription drug coverage with a temporary coverage gap known as the "Doughnut Hole."
Eligibility and Enrollment
- Individuals must be 65 or older or have received Social Security disability benefits for 24 months to qualify.
- Permanent residents who are illegal immigrants must reside in the U.S. for five consecutive years before being eligible for benefits.
Coverage Details
- Patients eligible for benefits are termed beneficiaries.
- Medicare Advantage plans may offer additional benefits beyond traditional Medicare, such as eyeglasses or prescription drugs.
- Medi-gap insurance assists with deductibles and co-payments not covered by Medicare.
Billing and Reimbursement
- Medicare identification is shifting from Social Security Numbers to Medicare Beneficiary Identifiers (MBIs), effective January 1, 2020.
- Participating physicians accept 80% of Medicare-approved charges. Nonparticipating physicians may impose limiting charges.
- Claims for medical services must be submitted within the year when services were provided.
Quality Control
- Quality Improvement Organizations (QIO) contract with CMS to ensure medical necessity for inpatient care.
- The Hospital-Acquired Condition Reduction Program (HACRP) incentivizes hospitals to minimize preventable conditions.
Enrollment and Premiums
- Beneficiaries might have premium increases annually for Part B coverage.
- Medicare covers certain services conducted during an individual's first year of enrollment.
Additional Points
- Medicare covers medical services related to fractures of the jaw, while dental care is typically excluded.
- There is no limit on the number of Medicare benefit periods a patient can experience, but each period must last for 60 consecutive days in a hospital or nursing facility.
- Nonparticipating physicians have an option to accept assignment, affecting how they bill patients.
Important Terminology
- Formulary: A list of covered drugs in each Medicare drug plan.
- Remittance Advice (RA): Document detailing claim decisions post-processing.
- National Provider Identifier (NPI): Unique ID for health care providers.
True/False Knowledge Check
- Medicare provides health coverage to disabled individuals after receiving Social Security disability benefits for 24 months.
- Not all individuals aged 65 meet the criteria for Medicare Part B.
- Medicare generally covers physical examinations within one year of enrollment.
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Description
Test your knowledge on Medicare fundamentals with these flashcards focusing on Chapter 6. Learn about key figures, agencies, and components of the Medicare program. Ideal for students or anyone looking to enhance their understanding of Medicare.
