B&C Chapter 14: Medicare

Question 1

advance beneficiary notice of noncoverage (ABN)

Answer 1

document that acknowledges patient responsibility for payment if Medicare denies the claim.

Question 2

benefit period

Answer 2

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

Question 3

conditional primary payer status

Answer 3

Medicare claim process that includes the following circumstances: a plan that is normally considered to be primary to Medicare issues a denial 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.

Question 4

coordinated care plan

Answer 4

also called managed care plan; includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs), through which a Medicare beneficiary may choose to receive health care coverage and services.

Question 5

demonstration/pilot program

Answer 5

special projects that tests improvements in Medicare coverage, payment, and quality of care.

Question 6

diagnostic cost group hierarchical condition category (DCG/HCC) risk adjustment model

Answer 6

CMS model implemented for Medicare risk-adjustment purposes and results in more accurate predictions of medical costs for Medicare Advantage enrollees; its purpose is to promote fair payments to managed care organizations that reward efficiency and encourage excellent care for the chronically ill.

Question 7

employer-sponsored group health plan (EGHP)

Answer 7

allows a large employer to assume the financial risk for providing health care benefits to employees; employer does not pay a fixed premium to a health insurance payer, but established a trust fund (of employer and employee contributions) out of which claims are paid.

Question 8

general enrollment period (GEP)

Answer 8

enrollment period for Medicare Part B held January 1 through March 31 of each year.

Question 9

hospice

Answer 9

autonomous, centrally administered program of coordinated inpatient and outpatient palliative services for terminally ill patients and their families.

Question 10

initial enrollment period (IEP)

Answer 10

seven-month period that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B.

Question 11

lifetime reserve days

Answer 11

may be used only once during a patient’s lifetime and are usually reserved for use during the patient’s final, terminal hospital stay.

Question 12

mass immunizer

Answer 12

traditional Medicare-enrolled provider/supplier or a non-traditional provider that offers influenza virus and/or pneumococcal vaccinations to a large number of individuals.

Question 13

medical necessity denial

Answer 13

denial of otherwise covered services that were found to be not “reasonable and necessary.”

Question 14

Medicare Advantage (Medicare Part C)

Answer 14

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.

Question 15

Medicare Cost Plan

Answer 15

type of HMO similar to a Medicare Advantage Plan; if an individual receives care from a non-network provider, the original Medicare plan covers the services.

Question 16

Medicare-Medicaid crossover

Answer 16

combination of Medicare and Medicaid programs; available to Medicare-eligible persons with incomes below the federal poverty level.

Question 17

Medicare Part A

Answer 17

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

Question 18

Medicare Part B

Answer 18

reimburses noninstitutional health care providers for outpatient services.

Question 19

Medicare Part D coverage gap

Answer 19

the difference between the initial coverage limit and the catastrophic coverage threshold, as described in the Medicare Part D prescription drug program administered; a Medicare beneficiary who surpasses the prescription drug coverage limit is financially responsible for the entire cost of prescription drugs until expenses reach the catastrophic coverage threshold; also called the Medicare Part D “donut hole.”

Question 20

Medicare Part D “donut hole”

Answer 20

the MMA private prescription drug plans (PDPs) and the Medicare Advantage prescription drug plans are collectively referred to as Medicare Part D; MMA requires coordination of Medicare Part D with State Pharmaceutical Assistance Programs (SPAPs), Medicaid plans, group health plans, Federal Employee Health Benefit Plans, and military plans such as TRICARE; Medicare Part D enrollment is voluntary, and beneficiaries must apply for the benefit.

Question 21

Medicare Part D sponsor

Answer 21

organization that has one or more contract(s) with CMS to provide Part D benefits to Medicare beneficiaries.

Question 22

Medicare Prescription Drug Plans

Answer 22

prescription drug coverage added to the original Medicare plan, some Medicare Cost Plans, some Medicare private fee-for-service plans, and Medicare Medical Savings Account Plans; Medicare beneficiaries present a Medicare prescription drug discount card to pharmacies.

Question 23

Medicare private contract

Answer 23

agreement between Medicare beneficiary and physician or other practitioner who has “opted out” of Medicare for two years for all covered items and services furnished to Medicare beneficiaries; physician/practitioner will not bill for any service or supplies provided to any Medicare beneficiary for at least two years.

Question 24

Medicare Secondary Payer (MSP)

Answer 24

situations in which the Medicare program does not have primary responsibility for paying a beneficiary’s medical expenses.

Question 25

Medicare SELECT

Answer 25

type of Medigap policy available in some states where beneficiaries choose from a standardized Medigap plan.

Question 26

Medicare special needs plans

Answer 26

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; such plans may limit membership to individuals who are eligible for both Medicare and Medicaid, have certain chronic or disabling conditions, and reside in certain institutions.

Question 27

Medication Therapy Management Programs

Answer 27

available to Medicare beneficiaries who participate in a drug plan so they can learn how to manage medications through a free Medication Therapy Management program; the MTM provides a list of beneficiary’s medications, reasons why beneficiaries take them, an action plan to help beneficiaries make the best use of medications, and a summary of medication review with the beneficiary’s physician or pharmacist.

Question 28

Medigap

Answer 28

supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the cost of Medicare deductibles, copayments, and coinsurance, which are considered “gaps” in Medicare coverage.

Question 29

opt-out provider

Answer 29

provider who does not accept Medicare and has signed an agreement to be excluded from the Medicare program.

Question 30

Original Medicare Plan

Answer 30

fee-for-service or traditional pay-per-visit plans for which beneficiaries are usually charged a fee for each health care service or supply received.

Question 31

private fee-for-service (PFFS)

Answer 31

health care plan offered by private insurance companies; not available in all areas of the country.

Question 32

Programs of All-inclusive Care for the Elderly (PACE)

Answer 32

optional Medicaid benefit for eligible enrollees; uses a capitated payment system to provide a comprehensive package of community-based medical and social services as an alternative to institutional care for persons aged 55 or older who require a nursing facility level of care.

Question 33

qualified disabled working individual

Answer 33

program that helps individuals who receive 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 exceeded the limit allowed; states are required to pay their Medicare Part A premiums.

Question 34

qualified Medicare beneficiary program

Answer 34

program in which the federal government requires state Medicaid programs to pay Medicare premiums, patient deductibles, and coinsurance for individuals who have Medicare Part A, a low monthly income, and limited resources, and who are not otherwise eligible for Medicaid.

Question 35

qualifying individual (QI)

Answer 35

program that helps low-income individuals by requiring states to pay their Medicare Part B premiums.

Question 36

respite care

Answer 36

the temporary hospitalization of a hospice patient for the purpose of providing relief for the purpose of providing relief from duty for the nonpaid person who has the major day-to-day responsibility for the care of the terminally ill, dependent patient.

Question 37

risk adjustment data validation

Answer 37

process of verifying that diagnosis codes submitted for payment by a Medicare Advantage organization are supposed by patient record documentation for an enrollee.

Question 38

roster billing

Answer 38

streamlines the process for submitting health care claims for a large group of beneficiaries for influenza virus or pneumococcal vaccinations.

Question 39

special enrollment period

Answer 39

a set time when individuals can sign up for Medicare Part B if they did not enroll in Part B during the initial enrollment period.

Question 40

specified low-income Medicare beneficiary

Answer 40

federally mandated program that requires states to cover just the Medicare Part B premium for persons whose income is slightly above the poverty level.

Question 41

spell of illness

Answer 41

formerly called spell of sickness; is sometimes used in place of benefit period.