****EXTRA CREDIT -- Medicare and Medicaid Ch 18

Question 1

the development of the medicare program can be traced back to…..

Answer 1

the 1935 social security act

Question 2

as mentioned, the development of the medicare program can be traced back to the 1935 social security act

explain this

Answer 2

medicare was NOT enacted at the time of the 1935 social security act.

however, this law marked the beginning of the federal government’s central role in the area of social insurance. the law was designed to provide for the material needs of americans

Question 3

explain when and how medicare was established

Answer 3

it was am amendment of the 1935 social security act

1965: title 18 of the social security act called “health insurance for the aged and disabled” amendment

Question 4

when and by whom was the CONCEPT of medicare introduced?

Answer 4

1952 by harry truman - suggested a health plan that would cover all social security beneficiaries.
he was not taken seriously

Question 5

what were the 3 major compromises proposed by Wilbur Mills in 1965 and what programs did they turn out to be

Answer 5

1. compulsory (required by law) health insurance program for the elderly which was to be financed by payroll taxes
2. voluntary insurance program for physician services
3. means-tested health insurance program for the poor

1st 2 – turned out to become medicare
3rd – medicaid

Question 6

what year was medicare officially signed into law and by whom

Answer 6

Lyndon B johnson in 1965

Question 7

medicare was traditionally a ____ part insurance program.
explain

Answer 7

2 part
part A – hospital insurance
part B – supplemental medical insurance (physican services and outpatient care)

Question 8

when was medicare part c added and what was it called

Answer 8

1997 – originally called medicare + choice program (now called medicare advantage)

Question 9

medicare part C expanded beneficiaries’ ability to participate in what?

Answer 9

wide variety of private health plans, including HMOs and PPOs

Question 10

what year and what law established medicare part D?

Answer 10

2003
Medicare Prescription Drug, Improvement, and Modernization Act

Question 11

who is entitled to receive part A automatically without paying any premium?

Answer 11

65 and older and….

1. if they are receiving/eligible to receive retirement benefits from social security or the Railroad retirement board

OR

2. had medicare-covered government employment

Question 12

What about people 65 and older who do NOT meet any of the 2 Part A criteria mentioned?

Answer 12

they can purchase part A for a monthly premium

Question 13

can people YOUNGER than age 65 receive part A without a premium?

Answer 13

YES

1. individuals who have received disability funds from social security/railroad retirement

2.patients with end-stage renal disease who require dialysis or transplant

Question 14

the NOn elderly account for about ____% of the medicare population

Answer 14

17%

Question 15

true or false

most medicare patients do not pay a premium for part A coverage, but EVERYONE who wants part B has to pay a monthly premium

Answer 15

true

Question 16

the expenses of providing medicare part A and B are paid from separate ___ ___

Answer 16

trust funds

Question 17

how are part A expenses paid?

Answer 17

from the hospital insurance trust fund – paid primarily through payroll taxes of employers, employees, and self-employed individuals

Question 18

ADMINISTRATION of the medicare program is the responsibility of whom?

Answer 18

the US dept of health and human services

Question 19

WITHIN the dept of health and human services, medicare elligibility and enrollment are the repsonsibility of whom?

who is responsible for carrying out most other duties related to medicare

Answer 19

eligibility and enrollment — Social Security Administration

other duties – CMS (centers for medicare and medicaid services)

Question 20

who manages the trust funds that fund part A and part B?

Answer 20

the US dept of treasury

Question 21

to be reimbursed for providing services to medicare patients, what must providers do?

Answer 21

-comply with medicare’s conditions of participation – related to the health and safety of medicare beneficiaries

Question 22

who assists CMS in the medicare certification process to determine if medicare will reimburse the provider/institution?

Answer 22

state agencies

Question 23

providers are paid for the services delivered to medicare patients AFTER they do what?

Answer 23

after they file claims with designated administrators (ie: blue cross/blue shield)

Question 24

who guards against unnecessary utilization of services?

Answer 24

administrators (ins companies like blue cross blue shield) that contract with CMS to administer part A and B claims

Question 25

how long is the benefit period for medicare part A beneficiaries in terms of hospital stay?

Answer 25

90 days.
lifetime reserve of 60 in case more than 90 is needed in one benefit period

Question 26

can a medicare beneficiary have several benefit periods during a given year? is there a lifetime limit?

Answer 26

yes they can have several in a year
no lifetime limit

Question 27

what does medicare part A NOT cover in hospitals

Answer 27

private room or amenities like TV or telephone

Question 28

what is medicare part A policy on psychiatric hospitals

Answer 28

maximum 190 days of inpatient psych care in a lifetime

Question 29

on days 1-60 of hospital stay, what does the patient pay

what about after 60 days?

Answer 29

days 1-60, patient pays deductible ONLY

after 60 days, they start cost sharing – copayments

Question 30

what is the medicare blood policy

Answer 30

may be another form of cost sharing for part A beneficiaries

pts may be required to pay the 1st 3 pints each year

Question 31

medicare patients are entitled to ____ days of care in a skilled nursing facility per benefit period

Answer 31

100

Question 32

what is the requirement for medicare to cover skilled nursing facility care

Answer 32

the pt must require daily skilled nursing or rehab services that can ONLY be provided in a skilled nursing facility

ALSO, must be preceded by a hospital stay of at least 3 days

Question 33

will medicare cover “skilled nursing facility care” for those who only need custodial care? (assistance eating, going to toilet, etc)

Answer 33

NO

Question 34

there is NO CHARGE to the patient in the first ___ days of skilled nursing facility care

Answer 34

first 20 days
after that = copayment

Question 35

both home health care and skilled nursing facility care coverage by medicare are designed for those who need ___ services, not ____

Answer 35

need SKILLED SERVICES, not unskilled (like custodial care)

Question 36

true or false

parts A and b share responsibility for home healthcare services

Answer 36

true

Question 37

what home health care services are NOT covered

Answer 37

meal preparation, delivery, and full-time nursing care

Question 38

medicare part A pays the entire bill for most covered services provided by approved home health agencies without ANY PATIENT COST SHARING

what is the exception?

Answer 38

durable medical equipment

patients must pay 20% coinsurance on this

Question 39

the hospice benefit of medicare part A provides care to patients who have life expectancies of ______ or less and who voluntariliy waive their right to treatment of their terminal illness

Answer 39

6 months or less

Question 40

short-term respite care in a nursing home or hospital (which provides temporary relief for the family members who regulary assist in home care) is covered for a maximum of ____ consecutive days

Answer 40

5

Question 41

hospice services are primarily delivered in a ____ setting

Answer 41

home

Question 42

true or false

a lot of cost sharing is required for covered services provided under the hospital benefit

Answer 42

FALSE – very little patient cost sharing is required

Question 43

what kind of emergency services does medicare part A cover?

Answer 43

emergency services received in ALL HOSPITALS, even those that do not participate in medicare (including hospitals in canada and mexico under some circumstances)

Question 44

true or false,

in GENERAL, medicare does not pay for healthcare services received outside of the US and its territories

Answer 44

TRUE – there are some emergency exceptions for canada and mexico, but that’s it

Question 45

Part B covers services provided by ____in ____ settings:

Answer 45

PHYSICIANS in a variety of settings such as hospitals, physician’s offices, nursing homes, and patient homes

Question 46

when a medicare patient undergoes an inpatient surgical procedure, explain the medicare coverage breakdown

Answer 46

part A pays for the hospital charges
part B pays for the surgeon’s services

Question 47

does part B cover any services that are NOT provided by physicians?

Answer 47

yes – PA’s, NP’s, and certified registered nurse anesthetists

Question 48

besides physicians, NP, PA etc provided services, what else does part B cover

Answer 48

outpatient hospital services, X-rays, labs, physical and occupational therapy, home health care (if not cov under part A)

Question 49

which part of medicare covers immunosuppressible drugs subsequent to a transplant, kidney dialysis, durable medical equipment, and ambulance transportation?

Answer 49

part b

Question 50

for which medical professionals is coverage under part B LIMITED

Answer 50

chiropracotrs, podiatrists, optometrists, and dental services

Question 51

name some services NOT covered by part B

Answer 51

physical exams
routine vision and hearing tests
hearing aids
routine dental care

Question 52

explain the cost sharing under part b

Answer 52

deductible is paid each year
after it is met, pts pay 20% of additional charges and medicare pays 80%

Question 53

what does it mean when a provider “accepts assignment?”
what happens if they don’t?

Answer 53

when they accept assignment, the amount they charge will equal medicare’s approved charge

if they DONT, the provider can bill more. however, there is a limit of 115% of medicare’s approved charges in place, so it can’t be too exorbitant

Question 54

how does medicare create incentives for physicians to agree on an ANNUAL BASIS to “accept assignment”

Answer 54

medicare pays participating physicians 5% higher than payments for nonparticipating physicians

Question 55

if physicians agree on an annual basis to accept assignments for all services provided to medicare beneficiaries, what are they referred to as?

Answer 55

medicare participating physicians

Question 56

what is one solution to controlling medicare spending?

Answer 56

to implement MANAGED CARE ORGANIZATIONS – have been successful in constraining costs in the private sector

they would get the same – if not better – level of service while also assisting in controling federal gov expenses

Question 57

in what time period did the number of beneficiaries in HMO’s increase substantially?

Answer 57

late 90s

Question 58

traditional HMOs was the only managed care option available to medicare beneficiaries from 1985 until the implementation of……… in_____

Answer 58

the balanced budget act of 1997 – medicare part c

Question 59

how did managed care options for medicare part C beneficiaries expand with the addition of part c in 1990

Answer 59

PPOs and other types of managed care plans

Question 60

the addition of new managed care options for medicare beneficiaries created what?

Answer 60

made the variety of plans available under medicare similar to those available to non-medicare patients
(called MEDICARE ADVANTAGE PLANS)

Question 61

if medicare part C plan costs are lower than medicare payments, what must these plans do?

Answer 61

pass the savings to beneficiaries in the form of lower premiums, reduced cost sharing, and/or additional benefits OR return the excess payments to medicare

Question 62

name 2 ways in which individuals who are enrolled in medicare can get prescription drug coverage

Answer 62

-enrolling in a freestanding (private) prescription drug plan while getting other medicare benefits

-joining a medicare advantage plan that covers ALL MEDICAL BENEFITS – including prescription drugs

Question 63

where does the funding for medicare part D come from

Answer 63

-premiums paid by those who have medicare advantage plans

-general fund from US treasury

-payment from states

Question 64

which medicare part has a “donut hole”

Answer 64

D

Question 65

donut hole is also known as a

Answer 65

coverage gap
-pay 100% of x dollar amount out of pocket

Question 66

if part D beneficiaries pay a certain $ limit on drugs, what kicks in?

Answer 66

medicare’s catastrophic coverage

Question 67

explain medicare part D’s catastrophic coverage

Answer 67

pts pay the greater of either:

-5% coinsurance
-copayments (certain dollar amt)

Question 68

are plans allowed to have formularies under part D?

Answer 68

yes

Question 69

true or false

part D coverage includes most FDA approved prescription drugs

Answer 69

true

Question 70

can medicare part D plans use cost sharing, PA’s, and other cost containment tools?

Answer 70

yes – as long as they’re not unduly restrictive

Question 71

true or false

medicare part d offers no subsidies for low income beneficiaries

Answer 71

false – they do

individuals with medicare and medicaid pay no deductible or premium and they have low copays depending on income

Question 72

what law brought important changes to medicare drug benefit such as rebates to cover the coverage gap?

Answer 72

affordable care act

Question 73

did part d have problems when it was launched

Answer 73

yes
widespread eligibility verification issues