Medicare Flashcards Chapter 15
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Questions and Answers

What does Medicare Part A or Medicare Hospital Insurance reimburse for?

  • Private insurance plans
  • Medications
  • Institutional providers for inpatient, hospice, and some home health services (correct)
  • Outpatient services

    • What is Medicare Part B or Medicare Medical Insurance responsible for?

  • Home health services
  • Inpatient services
  • Outpatient services (correct)
  • Long-term care

    • What is Medicare Advantage also known as?

    Medicare Part C

    What does Medicare Part D cover?

    <p>Prescription drug coverage</p> Signup and view all the answers

    What is the initial enrollment period (IEP) for Medicare?

    <p>Seven-month period</p> Signup and view all the answers

    When does the general enrollment period (GEP) for Medicare Part B occur?

    <p>January 1 through March 31 of each year</p> Signup and view all the answers

    What is the Special Enrollment Period (SEP) for Medicare Part B?

    <p>A set time when individuals can sign up if they did not enroll during the IEP.</p> Signup and view all the answers

    What does the Qualified Medicare Beneficiary program (QMBP) do?

    <p>Helps pay Medicare premiums, deductibles, and coinsurance for eligible low-income individuals.</p> Signup and view all the answers

    What is the role of the Specified Low-Income Medicare Beneficiary (SLMB) program?

    <p>Covers just the Medicare Part B premium for individuals above the poverty level.</p> Signup and view all the answers

    What does the qualifying individual (QI) program do?

    <p>Helps pay Medicare Part B premiums for low-income individuals.</p> Signup and view all the answers

    What is the purpose of the Qualified Disabled Working Individual (QDWI) program?

    <p>Helps individuals who lost Social Security and free Medicare Part A due to returning to work.</p> Signup and view all the answers

    What is the original Medicare plan?

    <p>Fee-for-service or traditional pay-per-visit plans.</p> Signup and view all the answers

    What marks the beginning and end of a Benefit Period?

    <p>Begins with hospitalization and ends after 60 consecutive days out of the hospital.</p> Signup and view all the answers

    What is synonymously referred to as Spell of Illness?

    <p>Benefit Period</p> Signup and view all the answers

    What are lifetime reserve days?

    <p>Days that may be used only once during a patient's lifetime for hospital stays.</p> Signup and view all the answers

    What is Hospice?

    <p>Program of coordinated palliative services for terminally ill patients and their families.</p> Signup and view all the answers

    What is the purpose of respite care?

    <p>Temporary hospitalization to relieve primary caregivers of their duties.</p> Signup and view all the answers

    What are coordinated care plans also known as?

    <p>Managed care plans</p> Signup and view all the answers

    What are private fee-for-service (PFFS) plans?

    <p>Healthcare plans offered by private insurance companies, not universally available.</p> Signup and view all the answers

    What do Medicare special needs plans cover?

    <p>Comprehensive care for those with chronic illnesses or specific needs.</p> Signup and view all the answers

    What is the DCG/HCC risk adjustment model?

    <p>A model for more accurate predictions of medical costs for Medicare Advantage enrollees.</p> Signup and view all the answers

    What is a Medicare Part D sponsor?

    <p>An organization that offers Part D benefits to Medicare beneficiaries.</p> Signup and view all the answers

    What is the Medicare Part D coverage gap also known as?

    <p>Medicare Part D 'donut hole'</p> Signup and view all the answers

    What is risk adjustment data validation (RADV)?

    <p>Verifying that diagnosis codes for payment are supported by patient records.</p> Signup and view all the answers

    What is a Medicare Cost Plan?

    <p>A type of HMO that covers services from non-network providers under original Medicare.</p> Signup and view all the answers

    What is a demonstration/pilot program in the context of Medicare?

    <p>A special project testing improvements in Medicare coverage and care quality.</p> Signup and view all the answers

    What is the purpose of Programs of All-Inclusive Care for the Elderly (PACE)?

    <p>To provide community-based care for elderly individuals needing nursing facility levels of care.</p> Signup and view all the answers

    What is the aim of Medication Therapy Management programs?

    <p>To help beneficiaries manage medication use effectively.</p> Signup and view all the answers

    What is Medigap?

    <p>Supplemental insurance covering Medicare deductibles and copayments.</p> Signup and view all the answers

    What is a Medicare SELECT plan?

    <p>A type of Medigap policy requiring beneficiaries to use certain providers.</p> Signup and view all the answers

    What defines an opt-out provider?

    <p>A provider who does not accept Medicare and is excluded from the program.</p> Signup and view all the answers

    What is a Medicare private contract?

    <p>An agreement between a beneficiary and a physician who has opted out of Medicare.</p> Signup and view all the answers

    What does the Advance Beneficiary Notice of Noncoverage (ABN) indicate?

    <p>Patient responsibility for payment if Medicare denies a claim.</p> Signup and view all the answers

    What is a medical necessity denial?

    <p>Denial of covered services deemed not 'reasonable and necessary.'</p> Signup and view all the answers

    What is conditional primary payer status?

    <p>Medicare claim process under specific circumstances where another payer is primarily responsible.</p> Signup and view all the answers

    What are Medicare Secondary Payer (MSP) situations?

    <p>Circumstances where Medicare is not primarily responsible for paying medical expenses.</p> Signup and view all the answers

    What does an employer-sponsored group health plan (EGHP) allow?

    <p>Larger employers to assume financial risk for providing health benefits.</p> Signup and view all the answers

    What is a Medicare-Medicaid crossover?

    <p>A combination of Medicare and Medicaid programs for eligible individuals.</p> Signup and view all the answers

    What is roster billing?

    <p>A streamlined process for submitting claims for vaccinations for large groups.</p> Signup and view all the answers

    What is meant by a mass immunizer?

    <p>A provider who offers vaccinations to a large number of individuals.</p> Signup and view all the answers

    Study Notes

    Medicare Overview

    • Medicare is a U.S. federal health insurance program for individuals aged 65 and older, and for certain younger people with disabilities.

    Medicare Parts

    • Medicare Part A: Covers inpatient hospital stays, hospice care, and some home health services.
    • Medicare Part B: Covers outpatient services provided by noninstitutional healthcare providers.
    • Medicare Advantage (Part C): Combines parts A and B into managed care plans, offering coordinated care and additional benefits.
    • Medicare Part D: Provides prescription drug coverage, available through various plans.

    Enrollment Periods

    • Initial Enrollment Period (IEP): Seven months for new beneficiaries to enroll in Parts A and B.
    • General Enrollment Period (GEP): Occurs annually from January 1 to March 31 for Part B enrollment.
    • Special Enrollment Period (SEP): Allows late enrollment in Part B under specific conditions.

    Financial Assistance Programs

    • Qualified Medicare Beneficiary Program (QMBP): State Medicaid programs cover premiums and deductibles for low-income individuals with Medicare Part A.
    • Specified Low-Income Medicare Beneficiary (SLMB): Covers only the Part B premium for those slightly above poverty levels.
    • Qualifying Individual (QI): Offers help for low-income individuals with Part B premiums.
    • Qualified Disabled Working Individual (QDWI): Supports disabled individuals returning to work by paying their Medicare Part A premiums.

    Medicare Coverage Structures

    • Original Medicare (Fee-for-Service): Traditional payment model where services are billed individually.
    • Benefit Period: Starts with hospital admission and ends 60 consecutive days after discharge.
    • Spell of Illness: Another term for benefit period.

    Hospice and Care Services

    • Hospice: Provides palliative care for terminally ill patients and their families.
    • Respite Care: Temporary care for hospice patients to relieve family caregivers.
    • Coordinated Care Plans: Includes various managed care options (HMOs, PPOs) for Medicare beneficiaries.

    Special Plans

    • Medicare Special Needs Plans: Tailored for individuals with specific chronic conditions requiring focused care.
    • Programs of All-Inclusive Care for the Elderly (PACE): Offers comprehensive community-based services for eligible elderly individuals.

    Risk Adjustment and Drug Management

    • Diagnostic Cost Group (DCG/HCC) Risk Adjustment Model: Ensures fair payment based on predicted costs for chronic illness care in Medicare Advantage.
    • Medication Therapy Management (MTM): Helps beneficiaries manage medications through personalized consultations.

    Supplementary Insurance

    • Medigap (Medicare Supplement Insurance): Covers Medicare's deductibles, copayments, and coinsurance.
    • Medicare SELECT: A type of Medigap policy that requires beneficiaries to use network providers.

    Provider Options

    • Opt-Out Provider: Physicians or practitioners who do not accept Medicare and are not eligible to bill Medicare beneficiaries.
    • Private Fee-for-Service (PFFS): Allows flexibility in accessing non-network providers, offered by private insurers.

    Billing and Payments

    • Advance Beneficiary Notice of Noncoverage (ABN): A document informing patients of potential payment responsibility if a service is denied by Medicare.
    • Conditional Primary Payer Status: Applies when Medicare may not be the primary payer due to ongoing appeals with other insurances.
    • Medicare Secondary Payer (MSP): Refers to scenarios where Medicare is not the primary coverage for beneficiary expenses.

    Immunization and Provider Categories

    • Roster Billing: Simplifies claims submission for groups receiving vaccinations.
    • Mass Immunizer: Providers or suppliers that administer vaccines to large populations.

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    Description

    Test your knowledge of Medicare with these flashcards from Chapter 15. This quiz covers essential aspects of Medicare Parts A, B, and C, including their definitions and services covered. Perfect for students in healthcare or insurance courses.

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