Medicare : Basic Principles of Medicare
Who reviews complaints about the quality of care given by skilled nursing facilities and inpatient hospitals?
QIO
What is an association of practicing doctors and other health care experts who work to improve the quality of health care in communities across America?
QIO (Quality Improvement Organization)
What group monitors appropriateness, effectiveness, and quality of care provided to Medicare patients?
Quality improvement organization (QIO)
For the first 30 months an individual has ESRD and has group health coverage through an employer or union and Medicare coverage, Medicare is:
Secondary
If an employed individual has group health coverage through an employer or union and Medicare coverage, Medicare is:
Secondary
If an individual has Workers Compensation group health coverage through an employer or union and Medicare coverage, Medicare is:
Secondary
If an individual has no-fault health coverage through an employer or union and Medicare coverage, Medicare is:
Secondary
All of the following are true statements regarding Medicare EXCEPT:
Unlike Social Security, it is not funded by payroll taxes.
Which entity reviews the medical necessity of admissions, duration of hospital stays, and the types of care provided to Medicare and Medicaid beneficiaries?
Utilization review comittee
What term is used for private organizations contracted to administer Medicare Part A benefits, enroll medical providers and investigate fraud?
Fiscal intermediaries
What terms is used for private organizations contracted to administer Medicare Part A benefits, enroll medical providers and investigate fraud?
Fiscal intermediaries
When can individuals sign up for Medicare Part B coverage that did not sign up upon initial eligibility?
General enrollment period
People of any age can qualify for Medicare coverage for all of the following, EXCEPT:
Have terminal cancer
J is almost 65 years old. What conditions must he meet to be eligible for Medicare?
He must be eligible for Social Security and apply for Medicare coverage.
K is not covered under Social Security, so how or when should she enroll in the Medicare program?
People like K, who are not covered under Social Security, often enroll for Medicare voluntarily during the month of their 65th birthday.
Physicians who do not accept assignment are termed:
Non-participating
When can individuals add a Medicare Part D plan if they did not select one when enrolling in Medicare Parts A and B?
Open enrollment period
When can individuals change from Original Medicare to Medicare Part C coverage?
Open enrollment period
Eligible individuals are automatically enrolled in what type of Medicare on the first day of the month in which they reach age 65?
Part A
Your client asks you about her eligibility for Medicare under Parts A and B. Which of the following would be an appropriate response?
Part A is primarily hospital coverage automatically available to persons age 65 and over, while Part B is optional medical care coverage available to those covered under Part A.
In 2006, federal legislation expanded Medicare to include which of the following?
Part D
Coverage provided under Medicare is divided into four parts. All of the following accurately describe the four parts of Medicare, EXCEPT:
Part D provides coverage for experimental treatments.
How long is the initial enrollment period (IEP) under Medicare?
Seven months
Jamie will turn 65 in September. Which of the following statements is true regarding her enrollment in Medicare Part A?
She will be automatically enrolled on the first day of the month in which she turns 65
If an individual has coverage under an employer group health plan and wants to enroll in Medicare, he or she qualifies for what type of enrollment?
Special enrollment
What program safeguards against unnecessary and inappropriate medical care rendered to Medicaid recipients?
Utilization review program
J is 64 years old and will be enrolling in Medicare this year. How long is the initial enrollment period for enrolling in Parts A and B?
seven months
D, who just turned 65, is not yet receiving Social Security retirement benefits, but she can enroll voluntarily in Medicare. What is the total length of her enrollment period?
seven months, ending three months after her 65th birthday
Medicare's system for paying physicians is based on which of the following?
A fee schedule
Medicare Part A covers:
Hospital
If S is covered by Social Security and is eligible for Medicare, her enrollment in Medicare Part B is automatic. What is the exception to this?
If S notifies the Social Security Administration that she declines to participate
What is the term for the dollar amount that Medicare considers to be the reasonable charge for a particular medical service?
Medicare approved charge
An individual who is not eligible for premium-free Medicare Part A coverage may apply for coverage during which of the following enrollment periods?
All of the above (Initial Enrollment Period, General Enrollment Period & Special Enrollment Period)
If an individual enrolls in Medicare before their birthday month and their birthday is NOT the first day of a month, when does coverage begin?
The first day of their birthday month
Medicare has how many enrollment periods?
3
To be eligible for Medicare, someone must have paid Medicare taxes for a minimum of how many years?
10
How much is the penalty for delaying enrollment in Medicare Part A or Part B beyond the initial eligibility period?
10%
Disabled Individuals are eligible to begin receiving Medicare Part A benefits after a waiting period of ____ months. Benefits will begin in the ____ month of disability.
24; 25th
To be eligible for Medicare, someone must have been a permanent legal residents for at least how many consecutive years?
5
What is the age for when people are normally eligible for Medicare?
65
All of the following statements about the Medicare program are correct, EXCEPT:
A 65-year-old not receiving Social Security retirement benefits is required to obtain coverage under Medicare Part A.
Which of the following statements about working and participating in Medicare Part B is correct?
A person can participate in Part B while still working, but it is voluntary.
Dr. S signed a Medicare participation agreement stating that he will accept the Medicare-approved amount as payment in full for his services. This means that Dr. S will submit claims to Medicare on what type of basis?
An assigned basis
Which of the following terms describes medical providers who accept the predetermined Medicare approved charge as full payment for covered services?
Assignment
B's Medicare benefits are paid directly to the health-care provider. What does the fact that Bob is eligible for Medicare coverage under Part A mean?
B is at least 65 years old and eligible for Social Security retirement benefits, or has received Social Security disability benefits.
B just enrolled in a Medicare Advantage Plan, while his brother T is covered by Original Medicare. Which of the following statements is correct?
B will receive his health care from a Medicare-sanctioned managed care HMO or PPO, while T can select his own provider.
Which entity oversees the administration and processing of Medicare Part B policies and claims?
Carrier
What is the term for private organizations that administer Medicare Part B benefits?
Carriers
Medicare makes what payment for services in which another payer may be responsible?
Conditional payment
What is a system of classifying hospital patients on the basis of diagnosis consisting of distinct groupings?
Diagnosis-Related Group
What term means the difference between the actual charge and the Medicare approved charge?
Excess charge
Which of the following is NOT a Medicare enrollment period?
Extended
Which entity handles claims for Part A from hospitals, skilled nursing facilities, home health agencies, and hospices?
Intermediary
Which of the following statements correctly describes enrollment in Medicare Part B?
It is automatic upon Medicare Part A enrollment, unless declined
Which statement about the supplementary medical insurance plan, Part B, of Medicare is correct?
It is optionally available to anyone covered under Medicare Part A.
When is the general enrollment period for Medicare?
January 1st through March 31st
Medicare regional policy guidelines are called:
Local Coverage Determinations
Who of the following will receive benefits under Medicare Part A?
M, who is receiving hospice care
What serves as the primary point of contact for provider enrollment and Medicare coverage?
MAC's (Medicare Administrative Contractors)
Which of the following are covered by Medicare Part C?
Managed care plans, preferred provider organizations, and private fee-for-service plans
E and his spouse are both 67 and retired. Their hospital and medical insurance would most likely be covered by which of the following?
Medicare
Who acts as the fiscal intermediary for Medicare?
Medicare Administrative Contractors
Who regionally manages policy and payment related to reimbursement for Medicare?
Medicare Administrative Contractors
Hospital coverage is provided by:
Medicare Part A
Individuals who are under the age of 65 and have disability will be automatically enrolled in __________ if they are receiving Social Security or RRB disability benefits.
Medicare Part A and Medicare Part B
An individual who is receiving Social Security benefits will be automatically enrolled in Medicare Part B upon:
Medicare Part A eligibility
Medical coverage is provided by:
Medicare Part B
Managed care coverage is provided by:
Medicare Part C
Prescription drug coverage is provided by:
Medicare Part D
Medicare made a conditional payment to cover J's medical expenses after he was injured by a third party in a car accident. What happens if the third party's insurance company reimburses J for his care?
Medicare can recover the conditional payment.
Which of the following statements best describes the Medicare program?
Medicare is a federal health insurance program designed specifically for people age 65 and over and for certain disabled people.
How would you explain the meaning of "Medicare approved" to a client?
Medicare must approve the health-care provider in advance.
Medicare Part B covers which of the following expenses?
Physicians' services
If a retired individual has group health coverage through an employer or union and Medicare coverage, Medicare is:
Primary
What is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount?
Prospective Payment System (PPS)
If an individual enrolls in Medicare before their birthday and their birthday is the first day of a month, when does coverage begin?
The first day of the month prior to their birthday
H is 67 years old, still working, and covered under his employer's group health plan. When H files a claim, how will it be paid?
The group plan is the primary payor, and Medicare is the secondary payor.
Eligible people who apply for Social Security retirement benefits at age 65 are automatically enrolled in Medicare Part A. What happens if a person does not apply for Social Security retirement benefits at age 65 but still wants Medicare?
The person must enroll for Medicare Part A.
How is Medicare Part A primarily funded?
Through FICA payroll taxes
What is the purpose of the utilization review program?
To safeguard against unnecessary and inappropriate medical care rendered to Medicaid recipients
Medicare Part C (Medicare Advantage) provides for which of the following?
an all-encompassing alternative to Parts A and B
A person eligible for Medicare Part A or Part B who missed the initial enrollment period (IEP) can sign up during an annual enrollment period (AEP), which occurs when?
between January 1 and March 31 each year
S, age 67, is covered by a group health plan that is scheduled to terminate on March 1. S can enroll in Medicare Part B without having to pay the 10 percent premium surcharge if he enrolls when?
during the eight-month period following the month his group coverage ends
M is a Medicare participant. For which of the following will he have to pay entirely out of his own pocket?
eyeglasses