| 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 |
