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Medicare, Medicaide, LTC NC Insurance
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Federal Program ✔✔Medicare is a federal health insurance program. Part of the Social Security program, Medicare is run by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services. Private firms contract with the federal government to handle the paperwork, review claims, and disburse claim payments.
Medicare Part A ✔✔Designed primarily to provide hospital insurance and to pay for certain other types of institutional care.
Medicare Part B ✔✔Designed primarily to provide medical insurance for physician visits and other out-patient care.
Medicare Part C ✔✔Provides expanded coverage through managed care plans such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
Medicare Part D ✔✔Provides coverage for prescription drugs.
What is the "original medicare"? ✔✔Parts A and B because those two parts were enacted together in the original amendment to Social Security that created the Medicare program in 1965. Parts C and D were added later (in 1997 and 2003, respectively) to keep the Medicare program up to date with changes in the health care delivery system.
If someone has Original Medicare, in which part or parts of Medicare is he or she enrolled?
A Parts A, B, and C
B Parts A, B, C, and D
C Part C
D Parts A and B ✔✔D Parts A and B
*Parts A and B are referred to as Original Medicare because they were enacted together when the So-cial Security law was originally amended to create Medicare. Parts C and D were added later.
Qualified Medicare Beneficiary (QMB) ✔✔Program is for persons whose monthly income is no more than the Federal Poverty Level (FPL) plus $20. Some states disregard more than an additional $20 of monthly income. In addition to helping pay the Part B premium, the QMB program may also help pay a beneficiary's Part A premium (if any) and Medicare cost-sharing amounts such as deductibles, coinsurance, and copayments.
Suppose a worker's income is between 120% and 135% of the federal poverty level. What is the name of the Medicare Savings Program for which she is eligible?
A Specified Low-Income Medicare Beneficiary
B Medicare Advantage
C Qualified Medicare Beneficiary
D Qualifying Individual ✔✔D Qualifying Individual
*The Qualifying Individual program pays the Part B premium for persons whose income is less than 135% of the federal poverty level but higher than the requirements for other Medicare savings pro-grams.
Medicare Advantage is another name for what part of Medicare?
A Parts A and B
B Part C
C Part D
D Part A ✔✔B Part C
*Medicare Part C is also called Medicare Advantage.
To be eligible to enroll in Medicare, individuals must fall into one of three groups. They must be: ✔✔-Age 65 or Older
- Social Security disability beneficiaries (generally after 2 years)
- Suffering from ESRD (end-stage renal disease—that is, kidney failure)
This is the largest group of Medicare beneficiaries. Most people become eligible for Medicare by reason of age ✔✔Age 65 or older group
Description of group 2 Social Security disability beneficiaries (generally after 2 years) ✔✔Individuals who have been receiving Social Security benefits because they are disabled and cannot work can become eligible for Medicare even if they have not yet turned age 65. Usually, such individuals become eligible for Medicare only after they have received Social Security disability benefits for a period of 24 continuous months (2 years).
Individuals who are eligible for medicare immediately ✔✔Individuals who qualify for Social Security disability benefits because they have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig's disease)
Description of group 3 who qualifies for Medicare Suffering from ESRD (end-stage renal disease—that is, kidney failure) ✔✔Individuals under age 65 can also become eligible for Medicare if they have had a kidney transplant or need regular dialysis because their kidneys no longer work.
By encouraging everyone to purchase Part B coverage when they are first eligible, ----------------- ------ ✔✔the late enrollment penalty maintains the expected balance of average and above- average risks in the insurance pool.
What is the additional enrollment penalty for Medicare part B? ✔✔An additional charge of 10% of the amount of the individual's Part B premium for every 12-month period that has elapsed since the individual became eligible for Medicare.
Suppose Jack became eligible for Medicare in January of 2013 but did not sign up for Part B until July of 2015. The standard price for Part B is $104.90 in 2015. ✔✔Although Jack waited 18 months after he first became eligible to sign up for Part B, only one period of 12 full months has elapsed, so his penalty would be an additional charge of 10% of his usual premium. The standard premium for Part B in 2015 was $104.90. Assuming that Jack, like most people, paid the standard premium, he would be charged an additional $10.49 (10% of the standard premium amount) for a total premium of $115.39 ($104.90 plus the $10.49 penalty). Jack would pay that additional 10% penalty for as long as he had Medicare Part B, not just for the first year. If the amount of the standard premium increased, the amount of the penalty would also increase to equal 10% of the higher premium.
What is the late enrollment penalty for Medicare Part A? ✔✔A similar 10% late enrollment penalty also applies to Part A coverage for individuals who do not get their Part A coverage premium-free.
For which of the following reasons do most people become eligible for Medicare?
A Payment of the Hospital Insurance payroll tax for 10 years
B Turning age 65
C Receipt of Social Security disability benefits for 2 years
D Kidney failure ✔✔B Turning age 65
*Medicare eligibility age is 65. Most people become eligible for Medicare by reason of age.
If an individual waited for 30 months after he first became eligible to sign up for Medicare Part B, what percentage would his late enrollment penalty be?
A 20%
B 25%
C 10%
D 30% ✔✔A 20%
18, and he signs up for Medicare in February, March, or April, his coverage becomes effective on May 1.
The one exception of coverage for individuals who enroll in Medicare in the first 3 months of IEP ✔✔If an individual's birthday is on the first day of the month, and the individual signs up during the first 3 months of the Initial Enrollment Period, coverage becomes effective on the first day of the month prior to his/her birthday month. For example, if Tamara's birthday is on May 1, and she signs up for Medicare in February, March, or April, her coverage becomes effective April 1.
For individuals who sign up during their birthday month during IEP, when does coverage start? ✔✔Coverage starts one month later
For individuals who sign up the month after their birthday month during IEP, when does their coverage start? ✔✔Coverage starts 2 months later.
For individuals who sign up 2 or 3 months after their birthday month (that is, during the last 2 months of their Initial Enrollment Period), when does coverage start? ✔✔Coverage starts 3 months later.
How many times does The Initial Enrollment Period occur during an individuals lifetime? ✔✔Only once in an individual's lifetime—it does not recur.
When will people retiring today at Social Security's normal retirement age usually sign up for Medicare?
A Before they retire
B After they retire
C At the same time they retire
D Before they retire and again after they retire ✔✔A Before they retire
*For people retiring today, Social Security's normal retirement age is 66. The age of eligibility for Medicare is 65.
If an individual turns age 65 in November, when does her Initial Enrollment Period for Medicare begin?
A August 1
B November 1
C October 1
D September 1 ✔✔A August 1
In SEP when does Part B coverage start? ✔✔In SEP, Part B coverage starts the month after the election is made.
What type of workers is the Special Enrollment Period made available to? ✔✔Special Enrollment Period is only made available to active workers covered by employer-sponsored group health insurance. COBRA coverage or retiree group health insurance (coverage provided to former workers who have retired) does not qualify.
Open Enrollment Period (OEP) ✔✔Each year between October 15 and December 7, Medicare beneficiaries are given an opportunity to make certain changes to their coverage.
During the Open Enrollment Period, what changes can beneficiaries make to their coverage? ✔✔-Change from Original Medicare to a Medicare Advantage plan, or change from a Medicare Advantage plan back to Original Medicare
-Switch from one Medicare Advantage Plan to another or
-Obtain, change, or drop their Medicare Part D prescription drug plan coverage
For individuals on Medicare who are still working at age 65 and are also covered by an employer-sponsored group health plan, the question arises: which plan is the primary payer in
the event of a claim, Medicare or the employer's group health plan? ✔✔The answer depends on the number of people working for the employer. If the employer has:
-Less than 20 employees, Medicare pays first
-20 or more employees, the employer's group health plan pays first
If the employer's plan is primary but does not pay the entire amount of a claim, what will Medicare do? ✔✔Medicare may pay secondary benefits for Medicare-covered services.
In the case of employees under age 65 who are on Medicare because of a disability, Medicare is the primary payer if the employer has how many employees? ✔✔In the case of employees under age 65 who are on Medicare because of a disability, Medicare is the primary payer if the employer has less than 100 employees.
The group health plan is the primary payer for disabled Medicare beneficiaries under age 65 only if ------. ✔✔The employer has 100 or more employees.
Prospective Payment System (PPS) (Medicare Prospective Payment System) ✔✔Introduced by the federal government, as a way to change hospital behavior through financial incentives that encourage more cost-efficient delivery of medical care.
Quality Improvement Organization (QIO) ✔✔The Centers for Medicare and Medicaid Services (CMS) uses these private firms to help improve services while controlling costs. CMS contracts with one firm in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands, to serve as that state's or jurisdiction's Quality Improvement Organization. QIOs are private, generally not-for-profit organizations, staffed mostly by doctors and other health care professionals. They are trained to review cases, handle complaints, and recommend improvements in the quality of care available throughout the spectrum of care. QIO contracts are 3 years in length.
*The use of QIOs is legally required by the Social Security Act.
By law, the mission of the QIO program is what? ✔✔To improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.
The core functions of the QIO program are: ✔✔-Improving quality of care for beneficiaries
-Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting
-Protecting beneficiaries by expeditiously addressing individual complaints such as: Beneficiary complaints, Provider-based notice appeals, and Violations of the Emergency Medical Treatment and Labor Act (EMTALA)
Medicare Part A (aka Hospital Insurance or HI)is called this because the main coverage it provides is for inpatient hospital care. But it also provides three other types of coverage: ✔✔- Skilled Nursing Facility care
-Home health care
-Hospice care
Under Medicare Part A, a benefit period is defined as the period of time that: ✔✔-Begins on the first day that a beneficiary is admitted to the hospital as an inpatient and
-Ends on the 60th day after the beneficiary has been discharged
If a beneficiary in Medicare Part A is readmitted to the hospital within 60 days of being discharged, the readmission is considered to be what? ✔✔An extension of the initial benefit period rather than the start of a new benefit period.
For the first 60 days of each benefit period for Medicare Part A ✔✔Medicare pays the entire cost of covered services, minus the amount of the Part A deductible. No matter how many benefit periods Medicare beneficiaries have in their lifetime, Medicare always pays the entire cost of the first 60 days, minus the deductible. This is referred to as an inexhaustible benefit.
*Inpatient benefit periods begin on the day a Medicare beneficiary is admitted to the hospital.
If a Medicare beneficiary is discharged from the hospital on September 15, on what date did his benefit period for this hospital stay end?
A October 14
B November 14
C September 30
D September 16 ✔✔B November 14
*Inpatient benefit periods end 60 days after a Medicare beneficiary is discharged from the hospital.
Covered Expenses Part A
Note that Medicare only pays for covered expenses. These include the following: ✔✔-Semi- private room
-Meals
-General nursing
-Miscellaneous hospital services and supplies, such as:
-Prescription drugs administered in the hospital
-X-rays
-Laboratory tests
-Operating and recovery room charges
-Rehabilitative services
Medicare Part A Exclusions ✔✔-private hospital room
-non-medical charges such as a television in the room
-Long-term care or custodial care (personal, non-medical care that can be provided by persons without medical training)
-Homemaker services
-Private nursing
-Cosmetic surgery (unless medically necessary, such as facial reconstruction)
-Experimental or alternative medicines or procedures, such as acupuncture
-Routine dental care or dentures
-Eye exams related to prescribing eyeglasses
-Hearing aids and exams for fitting them
For which of the following will Medicare pay?
A Exam for fitting hearing aids
