M11: Flashcards
The year Medicare was implemented
1966
The age of most individuals covered by Medicare
Age 65 or older
Hospital Insurance (HI)
Medicare Part A
Supplementary Medical Insurance (SMI)
Medicare Part B
Number of skilled nursing facility days under Medicare
Limited to 100 days per benefit period
% individuals must pay under Medicare for durable med. equipment
20% coinsurance
Begins with hospital entry, ends with a break of 60 days
Benefit Period Concept in Medicare Part A
Medicare Advantage Program, which expands options for participation in private-sector health plans
Medicare Part C
A type of Medicare Advantage plan. They’re not required to have networks of participation providers
Private fee-for service (PFFS) plans
Prescription drug insurance coverage
Medicare Part D
Coverage of long-term nursing care
Something not covered by Medicare
How the HI trust fund is financed
Primarily through mandatory payroll tax
Part A tax rate
1.45% of earnings paid by employees and employers
SMI is composed of 2 parts
Part B and Part D
Private health insurance that pays charges not covered by Parts A or B
Medigap
Number of lifetime reserve days for each beneficiary covered under Part A
60 additional hospital days
Medicare payments for most inpatient hospital services are made under this reimbursement mechanism
Prospective Payment System (PPS)
The Medicare rate is accepted as payment in full for a service provided
Doctor accepts assignment
Entities that process fee-for-service claims for both Part A & B services to providers/supplies in geographic jurisdiction
Medicare administrative contractors (MACs)
The part of Medicare with the greatest cost variation of any type
Part D plans
A comprehensive listing of maximum fees used to pay providers
Fee Schedule
Defined as the lowest of 1) the physician’s actual charge, 2) the physician’s customary charge, 3) the prevailing charge for similar services in the locality.
Reasonable Charges (used to pay Part B physicians prior to 1992)
Defined as the lesser of 1) the submitted charges, 2) the amount determined by a fee schedule based on a relative value scale.
Allowed Charges (used to pay Part B physician costs post 1992)
Defined as a fixed, predetermined amount per month per member is paid to the plan, without regard to the actual number and nature of services used by the members
Capitation - how Medicare Advantage pays
Processes and pays fee for service claims for both part A and Part B services to all providers and suppliers within its geographic jurisdiction
Medicare Administrative Contractors (MAC)
Groups of practicing healthcare professionals who are paid by the federal government to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries
Quality Improvement Organizations
