Understanding Medicare: A Comprehensive Guide, Exams of Nursing

Download Understanding Medicare: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! NC Medicare Supplement & Long Term Care Insurance Licensing Exam Solved 100% Correct!! Medicare Answer- Health insurance for those over age 65, people under 65 with certain disabilities & those with ESRD (end stage renal disease - permanent kidney failure requiring dialysis or kidney transplant) CMS Answer- Centers for Medicare and Medicaid Services administers the Medicare program. Social Security Administration handles most of the enrollment & plays a role in claims appeal process. MAC Answer- Medicare Administrative Contractor - company contracted to administer Part A & Part B claims. Medicare Part A Answer- -hospital coverage -no premium requirements for those with 40 "work credits" of FICA or Self Employment tax credits. -Those who don't qualify can voluntarily participate by paying a monthly premium Medicare Part B Answer- The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. -Has a monthly premium of $135.50 in 2019 which is deducted from SS check. -Part B enrollment is optional. You can reject Part B by signing a rejection form. Medicare Part C Answer- Medicare Advantage Plans that are offered through private insurance companies that provide both hospital and physician coverage and possible prescriptions - financed by Social Security and monthly premiums Medicare Eligibility Answer- -Over age 65 who have earned 40 "work credits" in order to receive premium free part A benefits -Permanently disabled prior to age 65 for at least 24 months -ESRD or kidney disease requiring dialysis or kidney transplant Medicare enrollment requirements Answer- Part A & B are automatically conducted by SSA when individual age 65+ enrolls for their Social Security retirement benefits Initial Enrollment Period Answer- 7 month period straddling 3 months before and ends 3 months after the individual turns 65, including the birthday month. -If enrollment is during the 3 mos prior to 65th birthday, coverage begins on 1st day of 65th birthday month -If enrollment is during or after 65th birthday month, coverage begins on 1st day of month after enrollment General Enrollment Period Answer- Medicare enrollment period - January 1st through March 31st annually. -Coverage begins July 1st of that year -Monthly premium for part B may go up 10% for each full 12 month period that you're eligible but didn't sign up. Special Enrollment Period Answer- Individual can enroll at 8 months beginning with the month employment ends or when group coverage ends whichever is earlier without subject to late enrollment surcharge Medicare as a secondary or primary payer Answer- -Medicare is the secondary payer for the 'working aged' who has a group health plan if the group has 20+ enrollees -For single employer with <20 employees with a group health plan, Medicare is the primary payer. -If individual retains coverage thru the group plan, the group contract is the primary unless person is retired & still covered under the group plan. In that case, Medicare is the primary. -If individual rejects the employer plan, Medicare is the primary payer Medicare as a secondary payer Answer- -In cases of Workers' Comp when it applies to an injury or illness - In cases where no-fault insurance or liability insurance is available as primary payer. Medicare & the VA Answer- Can choose to get treatment under either plan. Medicare usually will not pay benefits if services are rendered in a VA facility but will pay if outside of VA. There is NO coordination between Federal agencies. Expenses NOT paid by Medicare Answer- -Purely custodial care/ chronic care -Services that are not reasonable or medically necessary under Medicare standards -Services performed by relatives/ member of beneficiary's household -Services paid for by another gov't agency Medicare Part A covers Answer- -acute inpatient hospital care -inpatient skilled nursing care -medically necessary home health care & hospice services Medicare Deductible Answer- -Deductible must be met for ea. benefit period -Benefit period ends 60 days after discharge -Deductible is $1364 plus need to pay/ replace first 3 pts of blood per calendar year. Days 1 to 60 Answer- Non-Exhaustible Benefit -After deductible is met, Part A pays 100% of all approved hospital charges for first 60 days of confinement. From day 61 to 90th day of confinement Answer- Part A will pay 100% of approved charges less a copay of 25% of current deductible ($341) per day. -Also a non-exhaustible benefit Hospice Care (Medicare Part A) Answer- Hospice is for those in final stages (last 6 months) of terminal illness. Palliative care (pain relief, symptom mgmt & support) vs. curative care. -Hospice must be provided by CMS certified hospice. -Doctor must certify that patient is terminal with < 6 mo life expectancy -Patient choose hospice instead of standard hospital care -Part A pays 100% as long as beneficiary remains alive & terminally ill. -Benefit is provided thru 2 x 90 day and unlimited # of 60 day election benefit periods. -No deductible for hospice inpatient respite care Answer- A 5-day inpatient stay, provided on occasional basis to relieve the primary caregiver of terminally ill patient to give caregivers a break -Pays 95% if Medicare approved charge with patient paying 5%. Hospice benefits include Answer- -Nursing & doctors' services -Home health aide & homemaker services -Drugs used for pain or symptom relief (If drugs are administered on outpatient basis, patient must pay 5% but no more than $5 per Rx) -Medical supplies & appliances -Physical, occupational & speech therapy -Medical social services & counseling Medicare Part B benefits Answer- -Optional with premium payments -Annual deductible of $185 plus 3 pt blood deductible. -After deductible, 80/20 coinsurance -Benefit is based on approved charges (UCR) Participating Doctor Answer- Agrees to accept Medicare assignment payment method. -Patient pays 20% coinsurance after deductible. Non-Participating Doctor Answer- Doctor does not accept Medicare assignment -Allowed to charge more i.e. "Excess Charge" that what Medicare approves -Patient responsible for all charges in excess of the 80% approved charge by Medicare -Can accept assignment on a case by case basis Limiting charge (Medicare) Answer- The cap on the amount that can be charged above Medicare's approved amount by a Medicare NON-PAR provider that does not accept assignment on a claim. -Limited to charging an additional 15% over/ above Medicare approved charge Medicare Part B covers Answer- -Medical & surgical services incl. anesthesia, x- rays, med supplies, phys therapy, administered drugs -Diagnostic tests & procedures that are part of tx -Radiology & pathology (in- or out-patient) including radiation therapy -Mental illness tx as inpatient or under partial hospitalization. (Mental health tx in non-hospital outpt setting will receive pymt of 80% of approved charges) -Chiropractic services for manual manipulation of spine to correct dislocation confirmed by x-ray -Podiatrist to treat injuries or disease of the foot -Optometrist but not for routine care -Dental services if medical problem & dentist is involved in corrective procedure Medicare Part B does NOT cover Answer- -Routine physical exams & tests -Routine foot & dental care (diabetes is covered) -Exams for glasses or hearing aids -Routine immunizations (pneumonia, those required due to injury, hep B for high risk, flu shots ARE covered) -Elective cosmetic surgery (does cover reconstructive) Medicare Summary Notice (MSN) Answer- A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided -Sent quarterly- shows actual charge, approved am't, pt responsibility, deductible met. Medicare claims Answer- Provider has 1 year from date of service to file claim. Provider is responsible to filing the claim electronically. -If individual is filing they have up to 15 months to file. -MAC processes claim & decides what charges are covered by Part A based on DRG schedule. Appealing Medicare decisions Answer- 5 levels in Medicare A & B Appeals Process 1. Ask MAC to review decision within 120 days of receiving MSN 2. Ask QIC (Qualified Independent Contractor) for reconsideration 3. Request hearing before an Administrative Law Judge in the Office of Medicare Hearings & Appeals. 4. Request review by Medicare Appeals Council 5. File action in a Federal District Court for judicial review. Medicare Advantage (Part C) Answer- Managed care alternative to original program. Offered by Medicare-approved private companies that must follow Medicare rules. -Beneficiary must be enrolled in both Part A & Part B then elect a managed care plan in lieu. -Serviced thru MCO's network of providers. -Must accept all with Medicare except ESRD -Additional monthly premium in addition to Part B premium -Beneficiary must live in the plan's service area. Can elect HMO, PPO, POS or PFFS systems. -Can't use a Med Supp (Medigap) policy while participating. Medicare Outpatient Prescription Drug Coverage (Part D) Answer- Beneficiaries may choose to participate in a Prescription Drug Plan (PDP) that is offered by private sector insurance companies for an additional premium. -Must have Part A & Part B to join -Premiums based upon the PDP chosen Medicare Part D Enrollment Answer- -Initial Enrollment Period- can enroll without penalty -Open Enrollment/ Annual Election Period- Oct 15th to Dec 7th- coverage begins Jan 1 of following year -Late Enrollment- Any time after initial enrollment or a period of 63+ days where doesn't have Part D coverage. There's a penalty of +1% Part D premium for ea month of delay in enrollment Switching Advantage Part C Plans Answer- Can only be during Open Enrollment/ Annual Election Period - Oct 15th to Dec 7th of each year. Medicare Supplement Insurance (Medigap) Answer- Primarily intending to pay for cost-sharing feature of Medicare...i.e.. deductibles, coinsurance, expenses after Medicare is maxxed out. Types of Medicare Plans Answer- A, B, C, D, F, G, K, L, M -Do not have E, H, I, J -All companies marketing Med Supp must also offer plan A (basic/ core benefits) -Plan F is most popular Medicare Supplement - minimum standards Answer- Pre-existing coverage may be excluded from coverage for 6 mos max. -Impairment riders cannot be added to a Medigap policy. -Supplement policies may not indemnify sickness losses on a different basis than accident losses. -May not duplicate benefits of original plan or Medicare Advantage plan -Are "Issue Age" based, do not increase premium with age -Rates may NOT be based on "Attained Age" unless specified. -Must be either "Guaranteed Renewable" or "Non-cancelable" Insurers selling Medicare Supplement Insurance Answer- Required to pay out a certain percentage of premiums collected each year in benefits. Insurers are not allowed to make a high profit. -Group policies- at least 75% of aggregate premiums earned. -Individual policies- at least 65% Med Supp Disclosure Provisions Answer- -"Outline of Coverage" must be provided at time of application & a signed acknowledgement of receipt from applicant must be collected. -Must include renewal or continuation provision on first page -Riders added after issuance that affects policy coverage & premium must have a signed acceptance from insured -"Reasonable & Customary" must define the term & explained in outline of coverage. -ALL supplement policies MUST have a 30 Day Free Look Period -All applicant must be provided a NC Buyer's Guide from NAIC AND a Medicare Supplement Buyer's Guide from CMS at time of application.