Medicare basics

In order to qualify for hospice care, a patient must.

Be certified by a physician to have a life expectancy of six months or less.

Why are Medicare Advantage plans so diverse in their costs and offerings of service?

Because they are offered by private insurers.

A PPO organization will typically keep its members utilizing in-network providers how?

By making them cheaper then out of network providers.

An HMO organization will typically keep its members utilizing in-network providers how?

By not covering out of network care at all.

The fourth phase of prescription drug coverage is called what?

Catastrophic coverage. Begins at $5100 in 2019. During this phase, the plan pays for almost all the cost of the prescription drugs for the rest of the year, except for a small co-payment.

There is a co-insurance cost for a skilled nursing facility stay for what span of days?

Days 21 through 100

Which Medicare Advantage plan makes use of a primary care physician?

Health Maintenance Organization (HMO) use PCPs

Custodial care, or assisting a patient with activities of daily living, will only be paid for by Medicare if it is given.

Within a skilled nursing facility.

Is chemotherapy covered by Medicare?

Yes, if it is administered in a Doctors office, or in a clinical setting, it is covered by part B.

Do SNP plans include part D coverage?

Yes, they are all required to have part D coverage.

Which of the following is not one of the five major types of Medicare Advantage plans offered under Medicare Part C? Home Health Organization (HHO) plans private fee-for-service (PFFS) plans special needs plans (SNPs) preferred provider organization (PPO) plans

Home Health Organization (HHO) plans

Which of the following types of care is excluded by both Part A and Part B of Medicare a. most routine physical exams b. emergency room services c. ambulance services d. occupational therapy.

Most routine physical exams." Other than the initial "Welcome to Medicare" physical exam, most routine physical exams are not covered by Medicare Part A or Part B. The correct answer is A.

Under Part B, what is the charge for preventative services?

No charge for preventative services, meaning no co-insurance and no deductible if the provider accepts assignment.

Clinical Lab services, such as blood tests and urinalysis are covered by Medicare Part B at what cost?

No cost for testing, as long as the provider accepts assignment.

Name four examples of skilled care that qualify a patient to receive home health care coverage.

Skilled nursing care Physical therapy Speech or language pathology Occupational therapy

Which Medicare Advantage plans always includes prescription drug coverage?

Special Needs Plans (SNP) always include prescription drug coverage

If a patient is re-admitted to the hospital for any reason, even for the same issue, more then 60 days after the most recent discharge, what happens?

That beneficiary must pay an new part A deductible. They are in a new benefit period.

The total cost of a Medicare Advantage plan to the consumer includes what?

The Advantage plan premium, if any. The Part B premium The part A deductible The part B deductible The plans co-insurance, and/or co-payments

How does the CMS govern a plans listing of covered drugs?

The CMS attempts to insure that all major conditions are covered in each area by a plan formulary, and that beneficiaries in each area might have access to a formulary that will appropriately cover their personal condition. The plan itself is allowed to determine what drugs might be covered in order to treat a particular condition.

The Private Insurers offering a Medicare Advantage Plan get paid in what way?

The Centers for Medicare and Medicaid Services offer a fixed amount per enrolled individual in order to provide them care.

The Medicare deductible for skilled nursing facility care is.

$0. Since a patient can only be admitted to a skilled nursing facility after a minimum of three days in the hospital, the patient will have already paid the part A deductible.

The co-insurance, for a stay in a skilled nursing facility, when applicable, is.

$170.50 per day in 2019

If an in-patient hospital stay lasts more than 60 days, on day 61 the individual must begin paying a co-insurance of .

$341 in 2019

If a patient uses one of their lifetime reserve days, the co-insurance on those days is how much?

$682 in 2019

In Medicare D, what five types of expenses count toward reaching catastrophic coverage?

- The deductible - The amount paid during the initial coverage period - The amount paid during the coverage gap, including almost the full cost of brand-name drugs (including the manufacturer's discount) - The amounts paid by others, including family members, most charities, and other persons on your behalf - The amount paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and/or the Indian Health Service

What three common features are shared by all Medicare Advantage plans offered under Medicare Part C?

- They are all guaranteed issue. - They must all be at least as good as Original Medicare - Medicare pays the company offering the plan a fixed amount each month to provide the Medicare beneficiary with health care.

The cost sharing on the part of a patient that qualifies for home health care is

0%. The only cost to the patient is 20% of the medicare approved amount for durable medical equipment.

What two things must a part D plan include in order to be a qualified part D plan?

1. All plans must meet certain specific minimums, although plans are allowed to offer additional coverage and services that exceed the minimum requirements if they choose. 2. The premium and cost sharing requirements are approved by CMS and must appropriately reflect the value of the plan..

The Part B late enrollment penalty, also known as the Part B surcharge, is how much?

10% more for every full 12 month period that the individual did not have coverage that was at least as good as Medicare Part B.

The patient is responsible for all costs in a skilled nursing facility after how long?

100 Days

A health care providers ability to balance bill is limited to what percentage of the amount that Medicare will pay?

15%

The lifetime limit on in-patient hospital stays for mental health concerns is.

190 Days

Medicare will cover all of the cost for a stay in a skilled nursing facility for the first.

20 Days

In general, the cost sharing amount that the patient is expected to be responsible for under Medicare Part B is

20%

After a 90 day hospital stay, the patient will begin to use what is called their.

60 Day lifetime reserve.

A Medicare Part A in-patient benefit period starts on the day that a patient enters the hospital and ends when?

60 days after the patient is discharged.

For a skilled nursing facility, an in-patient benefit period starts on the day that a patient enters the hospital and ends when?

60 days after the patient is discharged..

Danita was discharged from the hospital on September 1. If she is not readmitted to the hospital in the meantime, when will her Part A benefit period covering this inpatient stay end? A. September 30 b. October 1 c. October 15 d. October 31

A benefit period ends 60 days after the patient is discharged from the hospital if he or she is not readmitted sooner. The answer is D

In a hospice situation, Medicare pays for the whole amount except for.

A copayment of $5.00 for prescription drugs used for symptom management and pain relief, and 5% of the cost of inpatient respite care stays.

A health provider is not required to accept the amount that Medicare will pay for covered services. If a medical provider decides to charge more, this is called what?

Balance Billing.

What are the two ways to get Part D?

A stand alone plan, As part of a Medicare Advantage plan

There are three main reasons why an individual may be eligible for Medicare. They are.

Ageing in at the age of 65, Being on disability for 24 months, End stage renal disease.

Medicare Part C plans are required to offer, at a minimum, what services?

All of the services of Original Medicare, parts A and B, with the exception of Hospice care.

Referrals are typically needed in what type of Medicare Advantage organization?

An HMO

Ted turns age 65 in June. When does his initial enrollment period for Medicare begin? a. February 1 b. March 1 c. June 1 d. July 1

An individual's initial enrollment period for Medicare is the seven month period that begins on the first day of the third month prior to the month in which the individual turns age 65. March is the third month prior to June, when Ted turns age 65. The answer is B.

The approved amount that Medicare will pay for specific covered services is called what?

Assignment

Medicare Part C plans frequently also provide what three services, in addition to the minimum required services?

Dental, vision and hearing, Health and wellness programs, Frequently, but not always, prescription drugs (Part D)

Name three services covered by Medicare in a Hospice case

Drugs for pain relief and symptom management, nursing and medical services, grief counseling and other social services not usually covered by Medicare

Mental Health Services are covered by Medicare Part B at what cost?

For diagnosis or physician monitoring visits, the beneficiary pays 20% and the Part B deductible applies. Outpatient psychiatric services are covered at between 20 and 40%, depending on the service, deductible applies.

How does a Medicare Advantage Special Needs Plan (SNP) work?

Generally, SNPs coordinate their services and providers to assure that patients receive all the care they need in the most efficient and effective manner. Often SNPs employ case managers or patient advocates who have nursing or other health-care credentials to create and monitor a care plan for each patient. The advocate may work with family members as well as the patient and providers to enhance the appropriateness and effectiveness of care.

Medicare will cover home health care under what four conditions?

If the care is medically necessary, ordered by a physician, provided by a Medicare-certified agency, and if the patient is home-bound, meaning that leaving home would require a great deal of effort.

The current in-patient hospital deductible is.

In 2019, this amount is $1364

When will the coverage gap close and what will the beneficiaries cost share amount be at that time?

In the year 2020, the cost share for the beneficiary will be 25%, which is considered a reasonable "coverage phase" cost-share.

There are five main things that Medicare part A cover. What are they?

In-patient hospitalization, skilled nursing facility care, In home care, hospice services, and blood.

If a patient is enrolled in a Medicare Advantage plan, Medigap, or a Medicare supplement, will perform what function?

It cannot be used with an Advantage plan, and it will not cover any co-pays, co-insurance or deductible on any part of a Medicare Advantage plan.

By law, what governs the part B premium amount?

It is set to cover 1/4th of the average cost of Part B services incurred by the average recipient, plus a contingency amount.

What is a formulary?

It is the plans list of covered drugs.

There are two conditions that must be met before Medicare will cover care in a skilled nursing facility. They are.

It must be immediately preceded by a hospital stay of at least three days, A physician must certify that such care is necessary.

A Medicare Advantage Medical Savings Account Organization works how?

It works similarly to an HSA account, but only the Advantage organization is allowed to fund the savings account.

As a general rule, the co-pays on an advantage plan are higher or lower then original Medicare?

Lower.

Under part A in-patient hospitalization care, Medicare will generally cover procedures and treatments that are considered what?

Medically necessary

Medicare Part C is also known as what?

Medicare Advantage

Do all Medicare Advantage plans include prescription drug coverage?

No they do not. You must check to make sure it is included.

Will everyone pay the same premium for the same Part D plan from the same MAO?

No, similar to part B premiums, beneficiaries with higher incomes may be required to pay higher premiums for coverage. This is known as the Income-Related Monthly Adjustment Amount or IRMAA

If a patient has used all of their lifetime reserve days, during the remainder of the hospital stay, Medicare will pay.

Nothing.

Referrals are typically not needed in what two types of Medicare Advantage organizations?

PPO. (Paid Provider Organization) PFFS (Paid Fee For Service)

If a patient is re-admitted to the skilled nursing facility for any reason, even for the same issue, more then 60 days after the most recent discharge, that individual is responsible for what?

Paying an new part A deductible. They are in a new benefit period.

Medicare part B premiums are indexed to income, which results in what?

People who have more money are expected to pay a higher premium for Part B

Which of the following types of health care is not covered by Medicare Part A? a. skilled nursing facility care b. hospice care c. physician care d. home health care.

Physician care (C). Services and items covered by Part A fall into five categories. inpatient hospital care, skilled nursing facility care, hospice care, home health care, and blood. Physician care is covered by Part B.

Medicare part B covers.

Physicians visits and outpatient care.

What are the five main types of Part C plans generally offered?

Preferred Provider Organizations (PPO), Health Maintenance Organizations (HMO), Medical Savings Account, (MSA) Private Fee For Service (PFFS), Special Needs Plans (SNP)

Describe a PPO organization.

Preferred provider organizations (PPOs) are companies that have contracted with various hospitals, physicians, and other types of health-care providers to form a network that offers a complete range of care.

What does Medicare Part D cover?

Prescription drugs

How does a Medicare Advantage Private Fee for Service plan (PFFS) work?

Private fee-for-service (PFFS) plans operate on a fee-for-service basis like Original Medicare, but they are different because it is the PFFS plan, rather than Medicare, that establishes the approved amount that will be paid for each service. Also, the cost-sharing provisions—deductibles, coinsurance percentages, and copayments—of a PFFS plan may be different than those of Original Medicare.

Custodial care outside of a skilled nursing facility can only be paid for by.

Private long term care insurance

How would a person qualify for Medicare without having worked 40 quarters?

Since non-working spouses can collect on the working spouses Social Security, non-working spouses may be eligible for part A by virtue of their spouses contribution.

Medicare will NOT cover home health care unless it includes.

Skilled care that falls into one of four categories.

What is the 2019 Part B deductible?

The Part B deductible is $185 for 2019.

In a hospice case, short term stays in a hospital, hospice center or a skilled nursing facility MAY be covered by Medicare if.

The care is required for pain relief and/or symptom management OR In order to provide some respite for the regular care-givers at home. (Up to five days at a time)

Under Part B, what is the charge for Medically Necessary services?

The co-insurance is 20% and in most cases, the deductible applies.

The third phase of prescription drug coverage is called what?

The coverage gap. During this phase, the beneficiary pays all costs and Medicare pays nothing. This phase continues until the beneficiaries total out of pocket costs reach the catastrophic limit. In 2019, this dollar range begins when the combined spending by the plan and the beneficiary reached $3820 and continues until the total spending by the beneficiary alone reached $5100.

The second phase of prescription drug coverage is called what?

The coverage phase. In this phase, the beneficiary and the plan share the cost of the drugs in accordance with the CMS approved cost sharing until the pre-determined dollar limit set by the Government is reached. In 2019, this range was from the end of the deductible phase ($415 max) until at least $3,820 has been spent by the plan and the beneficiary together for the drugs, including any deductible.

The first phase in a prescription drug plan is called what?

The deductible phase. There is a maximum deductible allowed by law, in 2019, this limit was $415. Not all plans charge the full amount allowed by law and some plans charge significantly less or nothing at all.

If a hospital charges a patient for blood, Medicare will cover all costs except for.

The first three pints as an inpatient recipient. If the blood is received as an outpatient, the blood is covered under part B, and the patient must pay for the first three pints, and then 20% of all remaining costs after that.

What is the premium for part B?

The part B premium is $135.50 in 2019.

Ted's health-care expenditures have satisfied his deductible under his medical savings account (MSA) plan. How will Ted's health-care expenses be paid from this point on?

The plan will pay all the health-care costs for the rest of the year.

What are the four major things a beneficiary must research in order to select the best possible Advantage plan for them?

The premium of the plan The cost sharing provisions of the plan, meaning co-pays, co-insurance and deductibles, If the drugs that they need are covered by the plan they are evaluating, The provider network the plan offers, and specifically, if the providers they want are part of it.

What is the usual coinsurance percentage that Medicare beneficiaries must pay for services covered under Part B of Medicare? a. 0 percent b. 20 percent c. 50 percent d. 80 percent

There are exceptions, but in general, Medicare beneficiaries are required to pay 20 percent of the cost of covered services received from health-care providers under Medicare Part B.

What three broad categories of beneficiary does a Medicare Advantage Special Needs Plan (SNP) cover?

Those with certain chronic or disabling diseases such as heart disease, diabetes, or HIV/AIDS, Those living in a nursing home or certain other institutions. Those who qualify for both Medicare and Medicaid ("dual eligibles")