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STACK 5
AAHAM CRCS STACK 5
| Question | Answer |
|---|---|
| What does MC part A cover and what is the cost? | -Medically necessary IP hospital -SNF -Home Health -Hospice * most don't pay a premium. Pts pay a deductible once/spell of illness (aka benefit period) which begins at admission and ends 60 days after discharge. |
| What is Medicare also known as and what act is it part of? | Title XVII (18) part of the social security act. |
| Who does Medicare cover? | 65+ People with permanent disabilities People with ESRD (End stage renal disease) People with Lou Gehrig's disease |
| What does LTR stand for and describe: | Lifetime Reserve: MC Part A gives a LTR of 60 days of inpatient hospital svc they can opt to use after using 90 days of in-pt in a benefit pd. The cost is 50% of the MC part A ded per day and it does not renew. |
| What does Medicare Part B cover? | Helps pay for doc svcs, OP hospital care, PT, OT, SOME home health care. Enrollment is voluntary, can sign up anytime within the 7 month period that begins 3 months before turning 65. - There is a premium paid for this coverage/ month |
| What is Medicare Part C and describe: | MC Advantage/replacement plan. Managed care coverage provided by private ins co approved by MC. Private ins co is paid a fixed amt / mo and must follow MC rules. |
| Types of Medicare Advantage Plans: (1 of 2) HMO PPO Private Fee for Svc Plan | HMO (Health Maintenance Org) -must get care form in-net providers. PPO (Preferred Provider org) -can see any provider that accepts MC, no referral needed for specialist. Private fee for svc plans -can go to any provider that accepts plan terms. |
| Types of Medicare Advantage Plans: 2 of 2) Special Needs Plan Medical Savings Account | Special Needs Plan: all or most members are in long term care facilities and eligible for MC/MA. Medical Savings Acct: has 2 parts, a MC advantage high deductible plan and a medical savings account managed by pt. |
| What is Medicare Part D? | MC Prescription Drug Plan Subject to annual deductible which varies, but the maximum allowed for 2023 is $505 Each drug is put into a tier, each tier has a different copay. |
| What does MAC stand for and describe: | MC Admin Contractor: Private firms that process MC claims. primary operational provider contact. Enroll providers in MC, provide edu on billing requirements, ans provider & pt inquiries. Currently 12 part a/b & 4 DME macs, process based on location. |
| What is the Medicare Participating Physician Program? | Prov accepts assignment yearly, stating that for MC pts: -will be paid by MC -get only MC allowed amt, no ABN allowed -charge pt only $ if non-cov svcs and co-ins/ded IF THEY DON'T SIGN: -Can charge up to 115% of approved amt -can ask pt to pay full |
| What does HICN / MBI stand for and what does it look like? | Health Ins Claim Number MC Beneficiary Identifier 11 characters, uppercase letters and numbers No commonly misread letters random alpha/numeric |
| Medigap | - MC supplemental ins -private policy to cover MC ded, co-ins and co-pays -only works with original MC plan |
| What is another name for Medicaid and who does it cover? | Title XIX (19) Low income adults, children, pregnant women, elderly adults and people with disabilities. Funded by Fed and state gov't. State have authority to: establish eligibility standards, determine what is covered and set payment rates |
| Tricare: who is covers and rules: | Active duty military and their spouses, dependents and retirees, unless eligible for MC. Military member = the Sponsor. Sponsor eligible day 1 of active duty, dependents eligible 30 days into active duty. Payer of last resort except for IHS and MA. |
| What does NAS stand for and what are the rules for it? | Non-availability Stmt before non-emer IP svcs can be provided to a Tricare Extra/standard Eligible bene by a non Mil Trtmt Fac (MTF) NAS issued by MTF Commander, valid 30 days and thru 15 days after discharge. Must go to MTF w/i a 40 mile catchment |
| What does CHIP stand for and who does it cover? | Children's Health Ins Program: Title XXI (21) Coverage for children when the family cannot afford private ins but does not qualify for MA. financed by fed and state gov't together. |
| What rules does the state set for CHIP program and what MUST be covered under this program? | State sets rules for eligibility standards, benefit coverage, pmt level, operating procedures. Must cover: in/out pt hospital care, Dr. surgical and medical services, well baby/child visits. |
| What does it mean to be self insured? | Co puts pmts into a fund & pays a TPA to admin pmts. Usually has a stop loss policy thru a reinsurer to alleviate the risk of a lot of unexpected claims. Regulated under fed law thru ERISA. may not have to follow timely pmt unless required by state. |
| What is commercial insurance? | Insurance co that covers individuals, usually obtained through insurance plan from employer. |
| What is liability insurance? | Usually covers an accident that was not work related. ex: Prop and Casualty, Auto) Some have med-pay (aka: no fault) coverage which pays quickly but not much. Liability ins will take long to pay b/c of litigation |
Created by:
Amy17349
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