Chapter 14 Medicare

Hospital ABN's are called

"Hospital-Issued Notices of Noncoverage (HNN)" or "Notices of Noncoverage."

Medicare Coinsurance and Copayment Amounts for Hospital Outpatient Services: James Hill underwent an outpatient oral glucose tolerance test. The charge for this procedure was $122. The fixed copayment for this type of procedure, adjusted for wages in the geographic area, is $20. How much is the patient required to pay to the hospital for the outpatient service provided?

$122 × 20% = $24.40, which is more than the copayment of $20; thus, the patient pays $20.

Medicare Coinsurance and Copayment Amounts for Hospital Outpatient Services: Sally Jones underwent outpatient surgery to have one mole removed from her upper back. The charge was $65. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. How much is the patient required to pay to the hospital for the outpatient service provided?

$13.00 - $65 × 20% = $13, which is less than the copayment of $15; thus, the patient pays $13.

Medicare Coinsurance and Copayment Amounts for Hospital Outpatient Services: Cherie Brown underwent an outpatient chest x-ray that cost $75. The fixed copayment for this type of procedure, adjusted for wages in the geographic area, is $25. How much is the patient required to pay to the hospital for the outpatient service provided?

$15.00 - $75 × 20% = $15, which is less than the copayment of $25; thus, the patient pays $15.

Medicare Coinsurance and Copayment Amounts for Hospital Outpatient Services: George Harris had a suspicious lesion removed from his left temple as an outpatient. The charge was $78. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. How much is the patient required to pay to the hospital for the outpatient service provided?

$15.00 - $78 × 20% is $15.60, which is more than the copayment of $15; thus, the patient pays $15.

Medicare Coinsurance and Copayment Amounts for Hospital Outpatient Services: Scott Wills underwent toenail removal as an outpatient. The charge was $81. The fixed copayment for this type of procedure, adjusted for wages in the geographic area, is $25. How much is the patient required to pay to the hospital for the outpatient service provided?

$16.20 - $81 × 20% = $16.20, which is less than the copayment of $25; thus, the patient pays $16.20

Up to what percentage of the plan's payment schedule are private fee-for-service (PFFS) plans authorized to charge enrollees?

115%

Medicare patients in a psychiatric hospital are allowed how many lifetime reserve days?

190

The minimum age for an individual to be eligible for Programs of All-Inclusive Care for the Elderly (PACE) benefits is:

55

Which is the total number of Medicare lifetime reserve days (defined as the number of days that can be used just once during a patient's lifetime)?

60

Medicare Part _____ reimburses institutional providers for inpatient, hospice, and some home health services.

A

Step 3

Assess whether Medicare covers the procedure or service.

What organization is responsible for overseeing Medicare?

Centers for Medicare and Medicaid Services

Step 2

Determine if Medicare is the primary payer.

Step 4

Determine if the patient has secondary coverage.

a characteristic of Medicare enrollment

Eligible individuals are automatically enrolled, or they apply for coverage

Which is a characteristic of Medicare enrollment?

Eligible individuals are automatically enrolled, or they apply for coverage.

If a patient has retiree group health plan coverage (including from his spouse's former employment), the group health plan pays __________.

First

Step 1 in Medicare claims process

Identify the procedure or service and where it was performed.

The general enrollment period (GEP) is held every year from:

January 1 through March 31

When a patient has Medigap coverage, what should be entered in Block 9A:

MEDIGAP and medicap plan policy number

In order to be paid for a service/procedure, a provider must establish

Medical necessity of the service/procedure.

The qualified disabled working individual (QDWI) program helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed, by requiring states to pay their:

Medicare Part A premiums

The original Medicare plan (or Medicare fee-for-service plan) includes:

Medicare Parts A and B

Which processes traditional Medicare claims?

Medicare administrative contractor

conditional primary payer status

Medicare claim process that includes the following circumstances: a plan that is normally considered to be primary to Medicare issues a denial of payment that is under appeal; a patient who is physically or mentally impaired failed to file a claim to the primary payer; a workers' compensation claim has been denied and the case is slowly moving through the appeal process; or there is no response from a liability payer within 120 days of filing the claim.

What is the name of the monthly explanation of benefits statement that Medicare patients receive?

Medicare summary notice

Coverage that will pay for Medicare patients' deductibles, coinsurances, and balances is known as:

Medigap insurance.

Enter this is box 11 if the patient does not have a group number or secondary insurance

NONE

What part of Medicare pays for physician services and outpatient hospital care?

Part B

Individuals age 65 or older who have group health insurance based on their own or their spouse's current employment can delay their Part B enrollment without having to pay higher premiums. These individuals can enroll any time during a(n)

SEP (special enrollment period)

If these codes are not listed or if the limitations exclude the condition, it is not likely that Medicare will cover the procedure. The patient would then need to sign an Advanced Beneficiary Notice (ABN).

You will still complete and submit a CMS-1500 but will need to use the modifier GX in Block 24 D.

A patient is asked to sign a (n) _ _ _ _ _ _ _ _ when there is a possibility that Medicare will not pay for the service

advance beneficiary notice

Which is a written document provided to a Medicare beneficiary by a provider prior to rendering a service that is unlikely to be reimbursed by Medicare?

advance beneficiary notice of noncoverage

Medicare Part C

aka medicare advantage includes managed care plans and private fee-for-service plans, which provide care under contract to Medicare and may include such benefits as coordination of care, reductions in out-of-pocket expenses, and prescription drugs. Medicare enrollees have the option of enrolling in one of several plans; formerly called Medicare+Choice.

Medicare coverage would be secondary to:

an employer group health plan

benefit period

begins with a Medicare subscriber's first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days

Medigap coverage is offered to Medicare beneficiaries by

commercial payers

Medicare Special Needs Plans (SNP)

covers all Medicare Part A and Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management

Skilled nursing facility (SNF) inpatients who meet Medicare's qualified diagnosis and comprehensive treatment plan requirements when they are admitted after a three-day-minimum acute hospital stay are required to pay the Medicare rate for SNF inpatient care during which period?

days 101+

The Medicare Part D coverage gap (or Medicare Part D "donut hole") for the Medicare Part D prescription drug program is best described as the:

difference between the initial coverage limit and the catastrophic coverage threshold

When completing a CMS-1500 claim for Medicare-Medicaid (Medi-Medi) crossover claims:

enter an X in both the Medicare and Medicaid boxes of Block 1

The Original Medicare Plan is also called Medicare

fee-for-service.

When reporting services provided during a hospitalization:

include hospitalization dates in Block 18.

demonstration/pilot program

is a special project that tests improvements in Medicare coverage, payment, and quality of care

Medicare SELECT

is a type of Medigap insurance that requires enrollees to use a network of providers (doctors and hospitals) in order to receive full benefits

balance billing

is forbidden as the result of legislation passed by some states

The supplier or provider should generate an advance beneficiary notice (ABN) if he or she believes that a claim for the services is likely to receive a:

medical necessity denial

Medicare Part D

offers prescription drug coverage to beneficiaries to help lower prescription drug costs

All providers must submit claims to Medicare for Medicare-covered services they have provided UNLESS:

patient is not covered by part B

Medicare Supplementary Insurance (MSI) is designed to supplement Medicare benefits by:

paying for services that Medicare does not cover

Which program helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts?

qualified Medicare beneficiary

Medicare Part A reimburses providers for:

reimburses institutional providers for inpatient, hospice, and some home health services.

Medicare Part B

reimburses noninstitutional health care providers for outpatient services; Occupational therapy may be covered in a limited way; aka medicare medical insurance

purpose of respite care is to provide:

relief for a nonpaid caregiver who is responsible for a terminally ill or dependent patient

To determine if a procedure is covered by Medicare:

search the Medicare Coverage Database

initial enrollment period (IEP) for Medicare Part A and Part B is

seven months

roster billing

simplified process was developed to enable Medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination programs offered by public health clinics

A federally mandated program that requires states to cover just the Medicare Part B premium for a person whose income is slightly over the poverty level is the:

specified low-income Medicare beneficiary

Hospice is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative services for:

terminally ill patients and their families

If a member of a Medicare Cost Plan receives care from a non-network provider:

the original Medicare plan covers the services

A Medicare benefit period is defined as beginning the first day of hospitalization and ending when

the patient has been out of the hospital for 60 consecutive days

A physician or practitioner with a Medicare private contract agrees not to bill for any service or supplies provided to any Medicare beneficiary for at least:

two years

A Medicare nonparticipating provider is not allowed to

utilize balance billing.

When you see both the CPT and the ICD-10 codes listed and have understood any limitations,

you can assume that Medicare will cover the charges

If billing an E & M service on the same day

you need to append modifier 25