Medicare 101

Question 1

In the scenario that a Medicare beneficiary has both Part A and Part B, she has an inpatient hospital stay that lasts for 80 days, after which she requires 30 days of skilled nursing facility care. Based on the 2023 Medicare fee schedule, what would be her total cost assuming she has no other form of supplemental coverage and her care is considered medically necessary?

Answer 1

Answer: $9,654

Explanation:
Part A of Medicare covers inpatient hospital stays, but the beneficiary is required to pay a deductible for each benefit period. In 2023, this deductible is $1,556. the first 60 days of hospitalization are covered without further cost after the deductible, but days 61-90 cost the patient $389 per day, for a total of $7,70. After the hospital stay, the beneficiary requires skilled nursing facility care, which is covered by Medicare Part A for up to 20 days with no coinsurance, but days 21-30 cost the beneficiary $194.50 per day, totaling $1,945. Adding these costs up, the total out-of-pocket cost for the beneficiary would be $1,556 (Hospital deductible) + $7,780 (Inpatient hospital stay day 61-8-) + $1,945 (Skilled nursing facility care days 21-30), equals $11,281.

Question 2

A Medicare beneficiary chose to enroll in a Medicare Advantage Plan (Part C). One day he was taken to the emergency department for severe chest pain, but later found out that the hospital was out-of-network according to his plan. What should he expect?

Answer 2

Answer:
The plan will cover the emergency service even though the hospital is out-of-network.

Explanation:

Medicare Advantage Plans, also known as Part C, are required by law to cover all emergency services, regardless of whether the provider is in-network or out-of-network. This means that if a beneficiary has an emergency situation, they can receive care from any hospital, and the plan will cover the costs.

Question 3

Mrs. White, a new Medicare Beneficiary, is keen to enroll in Medicare Part D. she is in her Initial Enrollment Period. When can she enroll in Part D?

Answer 3

Answer: She can enroll at any time during her Initial Enrollment Period.

Explanation:

The Initial Enrollment Period for Medicare Part D aligns with the initial enrollment for Medicare Part B. It is a 7-month period that includes the three months before, the month of, and the three months after the individual’s 65th birthday. During this period, an individual is able to enroll in a Medicare Part D plan without incurring any penalties. The enrollment in a Part D plan is not contingent on the enrollment in a Medicare Advantage Plan.

Question 4

Mr. Brown is a Medicare beneficiary who has just been diagnosed with achronic illness requiring specialty prescription medications. His current Medicare Part D plan covers his regular medications but does not cover these new specialty mediations. ‘what options are available to Mr. Brown/

Answer 4

Answer: He can appeal to the Part D plan to include his specialty medications.

Explanation:

If a necessary medication is not covered under a beneficiary’s Medicare Part D plan, the beneficiary has the right to request a formulary exception. This process involves the beneficiary’s doctor submitting a statement explaining the medical necessity of the drug. If the exception is granted, the Part D plan will cover the medication. Other options, such as changing plans or applying for Extra Help, would be valid during the annual enrollment period or if the beneficiary qualifies for Extra Help, respectively. However, these options are not immediately available or guaranteed, and therefore, an appeal is the most suitable option for Mr. Brown.

Question 5

Mrs. Johnson, a Medicare beneficiary, recently moved from Florida to Maine and wants to transfer her current Medicare Advantage Plan to her new state. Given the geographic restrictions of Medicare Advantage Plans, what will likely happen?

Answer 5

Answer: She will have to choose a new Medicare Advantage Plan that serves her new area.

Explanation:

Medicare Advantage Plans are offered by private companies that contract with Medicare and these plans must follow rules set by Medicare. However, each Medicare Advantage Plan can vary in cost and the specific rules for how you get services (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care). These plans are based on a network of providers that are geographically located, so if a beneficiary moves to a new state, she will likely need to select a new plan that has a provider network in her new location.

Question 6

Assume Mr. Smith, a Medicare beneficiary with Part A coverage, had an inpatient hospital stay that lasted for 50 days. After discharge, he required home health care service for 100 days. given the Medicare Part A rules for coverage of these services, what would be his total out-of-pocket cost assuming all the services are considered medically necessary and he has no other form of supplemental coverage?

Answer 6

Answer: $1,556

Explanation:

In 2023, Medicare Part A requires beneficiaries to pay a deductible for each benefit period for an inpatient hospital stay, which is $1,556. this covers the beneficiary for the first 60 days of hospitalization, so Mr. Smith’s 50-day hospital stary would be fully overed after this deductible. As for the home health care, Medicare Part A covers it 100% for up to 60 days with a doctor’s certification of need, and the patient is eligible for renewal of this service for further 60 days. Therefore, Mr. Smith’s 100 days of home health care would be covered completely, and his total cost for the scenario would be just the deductible for his hospital stay, which is $1,556.

Question 7

Mrs. Green, a Medicare Part A beneficiary, had a hospital stay that lasted 40 days. Forty days after her discharge, she requires skilled nursing facility (SNF) care. How will her SNF care be covered by Medicare Part A?

Answer 7

Answer: Her SNF care will not be covered by Medicare Part A.

Explanation:

Medicare Part A covers skilled nursing facility care only if certain conditions are met. One of the main conditions is that the beneficiary must enter the SNF within a short time (usually 30 days) of leaving the hospital. Since Mrs. Green is seeking SNF care 40 days after her discharge from the hospital, she would not be covered by Medicare Part A for this care.

Question 8

Mr. Collins is enrolled in Medicare Part A and is diagnosed with a condition that requires a semi-private room in a skilled nursing facility. His doctor has made the recommendation and he gets admitted for 25 days. What cost will Mr. Collins incur for this service?

Answer 8

Answer: He will not have to pay anything for his stay.

Explanation:

Medicare Part A covers the first 20 days of care in a skilled nursing facility completely, given that the stay is medically necessary and meets Medicare’s requirements. Since Mr. Colling is staying for 25 days, his stay for the first 20 days is covered completely, and for days 21 through 25, he would usually pay a coinsurance. However, the scenario does not provide this information, so we assume there are no extra costs.

Question 9

If a Medicare Part A beneficiary needs hospice care but decides to stay at home rather than go to a hospice inpatient facility, how does Medicare Part A coverage apply?

Answer 9

Answer: Medicare Part A will cover hospice care at home, including prescription drugs for symptom control and pain relief.

Explanation:

Medicare Part A provides coverage for hospice care when a doctor certifies that an individual is terminally ill and elects to receive hospice care. Coverage includes a variety of services necessary for the individual’s terminal illness and related conditions. This can include in-home support, nursing care, medical equipment, and prescription drugs for symptom control and pain relief. So if a beneficiary decides to receive hospice care at home, Medicare Part A will cover the necessary services.

Question 10

Mr. Peterson has Medicare Part A coverage. He was admitted to the hospital for surgery and discharged after 5 days. three weeks later, he had to be readmitted due to complications and stayed in the hospital for 15 days. What will be the total cost for Mr. Peterson for these hospital stays?

Answer 10

Answer: $1,556

Explanation:

Under Medicare Part A, a single deductible covers all hospital costs for the first 60 days of each benefit period. A benefit period begins the day the beneficiary is admitted to a hospital or skilled nursing facility and ends when the beneficiary has been out of the facility for 60 consecutive days. Since Mr. Peterson’s readmission to the hospital was within the same benefit period (it was within 60 days of his discharge), he only has to pay the deductible for his first hospital stay. The total cost for his hospital stays would be the deductible for the benefit period, which is $1,556 in 2023.

Question 11

Mr. Harris, who is already enrolled in Medicare Part A, is considering enrolling in Medicare Part B. He is also eligible for an employee group health plan through is current employer. given his employment status, what factors should Mr. Harris consider when deciding whether to enroll in Medicare Part B?

Answer 11

Answer: the size of the company he works for the cost of the premiums for the group health plan, and whether he is satisfied with his current coverage.

Explanation:

The decision to enroll in Medicare Part B can be influenced b several factors, including the size of the employer. If the company has 20 or more employees, the group health plan is usually the primary payer, and Medicare is secondary. If the company has fewer than 20 employees. Medicare is usually the primary payer. the cost of premiums for the group health plan and satisfaction with current coverage are also important factors to consider. The salary location of employment, job security, retirement plans, and personal preferences do not directly influence the decision to enroll in Medicare Part B.

Question 12

A Medicare beneficiary who is enrolled in Medicare Part B requires medically necessary ambulance services. What statement about these services is correct?

Answer 12

Medicare Part B covers ambulance services, but the beneficiary has to pay 20% of the Medicare-approved amount.

Explanation:

Under Medicare Part B, ambulance services are covered if they are considered medically necessary and if other means of transportation could be harmful to the beneficiary’s health. The beneficiary is generally responsible for 20% of the Medicare-approved amount for the ambulance service, after they have met the Part B deductible.

Question 13

Mrs. Allen, a beneficiary of Medicare Part B, has recently been diagnosed with diabetes. She requires diabetic supplies such as glucose monitors and test strips. how will these supplies be covered under Medicare Part B?

Answer 13

Answer: They are covered, but Mrs. Allen will have to pay 20% of the cost.

Explanation:

Medicare Part B covers some diabetic supplies, including blood glucose monitors and test strips. After meeting the Part B deductible, the beneficiary typically pays 20% of the Medicare-approved amount for these supplies. The remaining 80% is covered by Medicare.

Question 14

A medicare Part B beneficiary is in need of outpatient mental health services. What coverage can they expect or outpatient mental health services under Medicare Part B?

Answer 14

Answer: Medicare Part B covers outpatient mental health services, but the beneficiary has to pay 20% of the cost.

Explanation:

Medicare Part B covers mental health services for outpatient treatment, including services generally provided in a psychiatric or psychologist’s office, a hospital outpatient department, or a community mental health center. After meeting the Part B deductible, the beneficiary typically pays 20% of the Medicare-approved amount for mental health services provided by doctors and other providers.

Question 15

Mr. Jenkins, a beneficiary of Medicare Part B, requires a kidney transplant due to End-Stage Renal Disease. How is his transplant operation and related care covered under Medicare Part B?

Answer 15

Answer: Medicare Part B covers kidney transplants, but Mr. Jenkins must pay 20% of the cost.

Explanation:

Under Medicare Part B, kidney transplant services are covered, including transplant surgery, immunosuppressive drugs, and follow-up care. After meeting the Part B deductible, the beneficiary generally pays 20% of the Medicare-approved amount for these services. The remaining 80% is covered by Medicare. Therefore, Mr. Jenkins will have to pay 20% of the cost for his kidney transplant operation and related care.

Question 16

Mrs. Robinson is a Medicare beneficiary who is considering enrolling in a Medicare Advantage Plan (Part C). She is particularly interested in having her dental and vision services covered. What advice would you give her regarding Medicare advantage plans?

Answer 16

Some Medicare Advantage plans may cover dental and vision services, but it depends on the specific plan.

Explanation:

Unlike Original Medicare (Parts A & B), which offers the same coverage to everyone, Medicare Advantage Plans (Part C) can vary in the additional benefits they offer. Some, but not all, Medicare Advantage plans offer coverage for dental, vision, and other services not covered by Original Medicare. Therefore, Mrs. Robinson would need to review the specific benefits of each Medicare Advantage plan to determine if dental and vision services are covered.

Question 17

Mr. Johnson is a Medicare beneficiary enrolled in a Medicare Advantage Plan. He wants to switch to Original Medicare during the Open Enrollment Period from January 1 to March 31. Is this possible under Medicare rules?

Answer 17

Yes, and he can also join a Medicare Prescription Drug Plan.

Explanation:

During the Medicare Advantage Open Enrollment Period (January 1 to March 31), beneficiaries who are already enrolled in a Medicare Advantage Plan can switch to another Medicare Advantage Plan or witch to Origin Medicare (with or without a stand-alone prescription drug plan). Therefore, Mr. Johnson can indeed switch to Original Medicare and join a Medicare Prescription Drug Plan during this period.

Question 18

Mrs. Davis is interested in joining a Medicare Advantage Plan. However, she has concerns about her access to doctors and specialists. How does access to medical providers typically work under Medicare Advantage Plans?

Answer 18

Medicare advantage Plans typically have a network of doctors and hospitals that the beneficiary must use to get full coverage.

Explanation:

Medicare Advantage Plans, also known as part C, are offered by private insurance companies that contract with Medicare. These plans typically have a network of doctors and hospitals that beneficiaries must use to get the lowest out-of-pocket costs. If beneficiaries use providers outside of the plan’s network, they may have to pay more or all of the costs. Therefore, access to providers can be more limited under a Medicare Advantage Plan compared to Original Medicare.

Question 19

Mr. Anderson, a Medicare beneficiary with both Part A and Part B, is considering enrolling in a Medicare Advantage Plan. He is worried about potential out-of-pocket costs. what should he know about the out-of-pocket costs associated with Medicare Advantage Plans?

Answer 19

Medicare Advantage Plans have an annual limit on out-of-pocket costs for medical services.

Explanation:

One of the key features of Medicare Advantage Plans is that they have an annual limit on out-of-pocket costs for medical services. Once a beneficiary reaches this limit, the plan covers 100% of the costs for covered services for the rest of the year. This out-of-pocket limit can provide financial protection against high health care costs. It’s worth noting, however, that these limits can vary from plan to plan and do not include premiums or the cost of prescription drugs.

Question 20

Mrs. Thompson is a Medicare beneficiary enrolled in a Medicare Advantage Plan. She was recently diagnosed with a chronic illness and is interested in enrolling in a Special needs Plan (SNP). What requirement must she meet to be eligible to enroll in a SNP?

Answer 20

Answer: Se must have a specific disease or condition that the SNP is designed to serve.

Explanation:

Special Needs Plans (SNPs) are a type of Medicare Advantage Plan specifically designed for people wit certain types of diseases or characteristics. To join a SNP, a beneficiary must have the specific disease or condition that the SNP is designed to serve. Therefore Mrs. Thompson’s eligibility to enroll in a SNP would depend on whether her chronic illness matches the specific diseases or conditions that the SNP is designed to serve. Age, geographic location, and enrollment in other plans are not criteria for SNP eligibility.

Question 21

Mrs. green, a beneficiary of Medicare, is considering enrolling in a standalone Medicare Part D plan to cover her prescription drugs. What key factors should Mrs. Green consider when selecting a Part D plan?

Answer 21

Answer: The location of her residence, the premium amount, and whether her preferred medications are covered.

Explanation:

When selecting a Medicare Part D plan, beneficiaries should consider factors such as their geographical location (since plan availability can vary), The cost of the plan’s premium, and most importantly, whether their necessary medications are covered under the plan’s formulary.

Question 22

Mr. Smith, a Medicare beneficiary, is enrolled in a standalone Medicare Part D plan. He is concerned about the “donut hole,” or coverage gap, in his Part D coverage. Which of the following statement correctly describes this coverage gap?

Answer 22

Answer: Once Mr. Smith and his plan have spent a certain amount on covered drugs, he will have to pay the full cost of his drugs until he reaches his yearly out-of-pocket limit.

Explanation:

The “donut hole,” or coverage gap, is a term used to describe a gap in prescription drug coverage under Medicare Part D. Once Mr. Smith and his plan have spent a certain amount on covered drugs, he enters this coverage gap. During this period, he will pay more out of pocket for his medications until he reaches his yearly out-of-pocket spending limit. After reaching this limit, he will pay a smaller coinsurance or copayment for his drugs for the rest of the year.

Question 23

Mrs. Jones, a beneficiary of Medicare, is enrolled in a standalone Medicare Part D plan. She’s aware that each Part D plan ha a formulary, or a list of covered drugs. What can Mrs. Jone expect regarding her plan’s formulary?

Answer 23

Answer: The formulary may change, but the plan must follow rules set by Medicare.

Explanation:

Each Medicare Part D plan has a formulary, or a list of drugs that the plan covers. However, this formulary may change during the year, but the plan must follow rules set by Medicare. If the plan makes certain changes to its formulary during the year, it must provide written notice to all affected members at least 60 days prior to the change. Additionally, the plan cannot remove a drug form the formulary if a plan member is currently taking that drug, without giving them adequate notice and time to switch to a different drug or file an appeal.

Question 24

Mr. Martin, a Medicare beneficiary, is interested in joining a Medicare Prescription Drug Plan (Part D). However, he is concerned about the monthly premium. How is the monthly premium for Medicare Part D determined?

Answer 24

Answer: The monthly premium may vary depending on the specific plan and the beneficiary’s income.

Explanation:

The monthly premium for Medicare Part D plans may vary depending on the specific plan and the beneficiary’s income. Each plan sets its own monthly premium. In addition, individuals with higher incomes (over a certain limit) may have to pay an extra amount in addition to their plan premium, which is known as the Income-Related Monthly Adjustment Amount (IRMAA).

Question 25

Mrs. Taylor, a Medicare beneficiary, recently joined a Medicare Part D plan. She is concerned about her coverage for a specific brand-name drug that he takes regularly. The drug is covered by her plan, but she’s surprised to find that she must pay a higher cost for it. What could be a possible explanation for this?

Answer 25

The drug is listed on a higher tier of her plan’s formulary.

Explanation:

Most Medicare Part D plans have a formulary that categorizes drug into different “tiers” Each tier has a different cost associated with it. Generally, drugs on lower tiers cost less, while drugs on higher tiers cost more. If Mrs. Taylor’s brand-name drug is listed on a higher tier of her plan’s formulary, she would likely have to pay more out of pocket for it. Note that some drugs can be moved to a lower cost tier if the prescriber can show the plan that a lower-tiered drug won’t work for the beneficiary, which is known as a formulary exception.

Question 26

Mr. Miller, a Medicare beneficiary, is considering purchasing a Medigap policy to help cover out-of-pocket costs not covered by Original Medicare. What should Mr. Miller understand about the timing of purchasing a Medigap policy?

Answer 26

Answer: He has a one-time 6-month Medigap Open Enrollment period that begins when he’s 65 or older and enrolled in Medicare Part B.

Explanation:

The best time for a Medicare beneficiary to buy a Medigap policy is during their 6-month Medigap Open Enrollment Period. This period starts that first month they’re covered under Medicare Part B and they’re 65 or older. During this period, an insurance company can’t refuse to sell them any Medigap policy it offers, charge them more because they have health problems, or make them wait for coverage to start (except in some situations).

Question 27

Mrs. Johnson, a Medicare beneficiary, is enrolled in a Medicare Advantage Plan. However, she is considering switching back to Original Medicare and purchasing a Medigap policy. What should she understand about her ability to purchase a Medigap Policy?

Answer 27

Answer: She can only purchase a Medigap policy if she cancels her Medicare Advantage Plan and witches back to Original Medicare

Explanation:

Medigap policies are designed to supplement Original Medicare, not Medicare Advantage Plans. If Mrs. Johnson wants to purchase a Medigap policy, she would first need to leave her Medicare Advantage Plan and return to Original Medicare. It’s also important to not that there may be limitations on when she can switch back to Original Medicare and when she can buy a Medigap policy..

Question 28

Mr. Davis, a Medicare beneficiary, recently purchased a Medigap policy. He is concerned about potential changes to his policy’s coverage and cost. Which of the following statements is correct regarding Medigap Policies?

Answer 28

The cost of his Medigap policy may go up over time.
Explanation:

Medigap policies are standardized, and the benefits do not change from year to year. However, the premium may increase over time, depending on the type of pricing method used by the insurance company. An insurance company cannot cancel a Medigap policy as long as the policyholder pays the premium. Lastly, Medigap policies generally only cover the policyholder, not their spouse.

Question 29

Mrs. Robinson, a Medicare beneficiary, is considering purchasing a Medigap policy. She has heard about “guaranteed issue rights” but is unsure of what they are. What do guaranteed issue rights provide for Mrs. Robinson?

Answer 29

Answer: They guarantee that Mrs. Robinson can buy any Medigap policy sold in her state regardless of her health status in certain situations.

Explanation:
Guaranteed issue rights, also known as “Medigap protections,” are rights a person has in certain situations when insurance companies must offer them certain Medigap Policies. In these situations, an insurance company must sell them a policy, cover all their pre-existing conditions, and cannot charge them more for a policy because of their health status.

Question 30

Mr. Thompson, a Medicare beneficiary, recently moved from Texas to California and he currently has a Medigap policy. He is wondering whether his Medigap policy will cover him in his new state. Which of the following statements correctly describes his situation?

Answer 30

Mr. Thompson’s Medigap policy will cover him in any state.

Explanation:

Medigap policies are standardized across states, and they provide coverage anywhere in the U.S. Therefore, if Mr. Thompson moves to a different state, his Medigap policy will still cover him. However, if he decides he wants to switch to a different Medigap policy, or if he’s just moving to a new address within his state, he should contact his insurance company so his Medigap policy can be updated.

Question 31

Mrs. Stevens, who will soon turn 65, is considering her options for enrolling in Medicare. She is not yet receiving Social Security or Railroad Retirment Board benefits. When is the earliest that she can apply for Medicare?

Answer 31

Answer: Three months before her 65th birthday.

Explanation:

The Initial Enrollment Period (IEP) for Medicare begins three months before the month an individual turns 65 and continues for seven months. Since Mrs. Stevens is not yet receiving Social Security or Railroad Retirement Board benefits, she will need to apply for Medicare during this IEP.

Question 32

Mr. Lawson a Medicare beneficiary, wishes to add a Medicare Advantage Plan and currently it’s February. When is the earliest that he can make this change?

Answer 32

Answer: During the next Open Enrollment Period, which begins on October 15.

Explanation:

The Annual Open Enrollment Period for Medicare runs from October 15 to December 7 each year. this is the period when all Medicare beneficiaries can change their Medicare health plans and prescription drug coverage for the following year. Since it’s February, Mr. Lawson will need to wait until the next Open enrollment Period to add a Medicare Advantage Plan.

Question 33

Mrs. Harris missed her Initial Enrollment Period for Medicare and doesn’t qualify for a Special Enrollment Period. She is considering enrolling during the General Enrollment Period. When does the General Enrollment Period occur?

Answer 33

Answer: January 1 through March 31 each year.

Explanation:

If an individual didn’t sign up for Part A (if they have to buy it) and/or Part B (for which they must pay premiums) during their Initial Enrollment Period, and they don’t qualify for a Special Enrollment Period, they can sign up during the Medicare General Enrollment Period that runs from January 1 through March 31 each year.

Question 34

Mr. Chen is a Medicare beneficiary who has just moved to a new state. He wants to switch to a Medicare Advantage Plan that is available in his new area. Does Mr. Chen qualify for a Special Enrollment Period to make this change?

Answer 34

Answer: Yes.

Explanation:
Certain life events or changes in circumstance, such as moving to a new address, can trigger a Special Enrollment Period (SEP). During this time, Mr. Chen can make changes to his Medicare coverage outside of the usual enrollment periods. In this case, moving to a new state where different Medicare Advantage Plans are available would qualify him for a SEP.

Question 35

Mrs. Patel is 67 and has been continuing to work after turning 65, with health coverage from her employer. She is now considering retirement and will lose her employer’s coverage. When can she enroll in Medicare Part B without facing a late enrollment penalty?

Answer 35

Answer: She can enroll anytime within 8 months of her retirement.

Explanation:

Mrs. Patel can sign up for Medicare Part B without penalty during her Special Enrollment Period (SEP). The SEP for people covered under an employer group health plan allows an individual to sign up for part B anytime while still covered by the group health plan or within 8 months of the individual or spouse’s employment or the group health coverage ending, whichever happens first. Since Mrs. Patel is retiring and losing her employer’s coverage, she can use her SEP to enroll in Part B without facing a late enrollment penalty.

Question 36

Mr. Brooks, who will soon turn 65, has worked and paid Medicare taxes for 35 years. He’s interested in understanding the costs associated with Medicare Part A when he becomes eligible. What can Mr. Brooks expect regarding the Part A premium?

Answer 36

Answer: He will not have to pay a monthly premium for Medicare Part A.

Most people do not have to pay premium for Medicare Part A. This is because they or a spouse paid Medicare taxes while thy were working. In Mr. Brooks’ case, because he worked and paid Medicare taxes for over 10 years (40 quarters), he is eligible for premium-free Part A

Question 37

Mrs. Lewis is a Medicare beneficiary with a Medicare Part B premium. Her monthly income is $1,500, and she is finding it difficult to afford the premium. Can Mrs. Lewis apply for help to pay her Part B premium?

Answer 37

Answer: Yes, she can apply for the qualified Medicare Beneficiary (QMB) Program.

Explanation:

The Qualified Medicare Beneficiary (QMB) program is one of several programs that help people with limited income and resources pay for their Medicare costs. The QMB program helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments. Each state has its own income and resources limits that a person must meet to qualify for the QMB program.

Question 38

Mr. Henderson has recently been hospitalized for a hip replacement surgery. He has Medicare Part A coverage. Which of the following costs would he likely incur for this hospital stay under Part A?

Answer 38

Answer: He would pay a deductible for his hospital stay.

For each benefit period, Medicare Part A beneficiaries must pay a deductible before Medicare will start to cover costs. The benefit period starts the day the beneficiary is admitted as an inpatient in a hospital. It ends when the beneficiary hasn’t had any inpatient hospital care for 60 days in a row.

Question 39

Mrs. Evans, a Medicare beneficiary, sees her primary care doctor four times a year under Medicare Part B. How much will Mrs. Evans typically pay for these office visits if the doctor accepts assignment.

Answer 39

Answer: She will pay 20% of the Medicare-approved amount for each visit.

Explanation:

After beneficiaries meet their annual Part B deductible, they typically pay 20% of the Medicare-approved amount for most doctor services. This includes services in their doctor’s office, as well as in an outpatient.

Question 40

Mr. Wilson is enrolled in a Medicare Advantage Plan (Part C) and wants to understand the maximum out-of-pocket limit for his plan. What is the highest amount that his plan can set for his out-of-pocket maximum?

Answer 40

Answer: $6,700 per year.

Explanation:

All Medicare Advantage Plans have an out-of-pocket maximum. This is the most a beneficiary will have to pay for covered services in a plan year. For Medicare Advantage Plans, the out-of-pocket limit can be different between plans but cannot be more than $6,700 per year for in-network services. Some plans might choose to set a lower out-of-pocket limit, offering an additional layer of consumer protection.

Question 41

Mr. Jenkins has been diagnosed with a chronic condition requiring skilled nursing care. He has been admitted to a skilled nursing facility (SNF) for an extended stay. How many days of care in the SNF will Medicare Part A cover at 100%

Answer 41

Answer: The first 20 days.

Explanation:

Medicare Part A covers the full cost of skilled nursing care for the first 20 days per benefit period in a skilled nursing facility following a qualifying hospital stay of at least 3 days. After the first 20 days, beneficiaries are required to pay a daily coinsurance amount for day 21 - 100 in a benefit period. Beyond 100 days in a benefit period, Medicare doesn’t cover SNF care.

Question 42

Mrs. Thompson is considering enrolling in a Medicare Advantage Plan and is concerned about her current prescription medications. She wants to know if her drugs will be covered under a Medicare Advantage Plan. What should she do to ensure her medications are covered.

Answer 42

Answer: She can look at the specific plan’s formulary before deciding to enroll.

Explanation:

Each Medicare Advantage Plan that includes prescription drug coverage has its own list of covered prescription drugs, called a formulary. The formulary may change, but the plan will notify members when necessary. Before Mrs. Thompson enrolls in a Medicare Advantage Plan, she should review the plan’s formulary to ensure that her medications are covered

Question 43

Mr. Davis has just been discharged from the hospital after a stroke and now needs outpatient physical therapy. Will his outpatient therapy be covered under Medicare Part B?

Answer 43

Answer: Yes, Medicare Part B covers outpatient physical and occupational therapy.

Explanation:

Medicare Part B covers medically necessary outpatient physical and occupational therapy. As long as the therapy is ordered by a doctor and provided by a Medicare-certified therapist, it will be covered.

Question 44

Mrs. Allen is enrolled in Medicare Part B and has been diagnosed with diabetes. She wants to participate in a self-management training program to understand how to manage her disease. Will Medicare cover this training?

Answer 44

Yes, Medicare Part B covers diabetes self-management training.
Explanation:

Medicare Part B covers diabetes self-management training (DSMT) for beneficiaries who have been diagnosed with diabetes. DSMT provides training on how to cope with and manage diabetes and it must be prescribed by a healthcare provider.

Question 45

Mr. Jackson, a Medicare beneficiary, needs a routine eye exam to check for vision problems. Will Medicare Part B cover this service?

Answer 45

No, Medicare Part B does not cover routine eye exams.
Explanation:
Medicare Part b typically does not cover routine eye exams for eyeglasses or contact lenses. However, Part B can cover certain preventive or diagnostic eye exams. For instance, if Mr. Jackson had diabetes or age-related macular degeneration, Medicare could cover an annual eye exam. Medicare may also cover glaucoma tests for people at high risk for glaucoma. It’s important for beneficiaries to understand what services are covered and under what conditions to avoid unexpected out-of-pocket costs.

Question 46

Mr. Rivera has Original Medicare, and a claim for a medical service he received has been denied. He disagrees with this decision and wants to challenge it. What is the first level of appeal he should go through?

Answer 46

Answer: Request a redetermination from the Medicare Administrative Contractor.

Explanation:

The first level of appeal in the Original Medicare (Part A and Part B) appeals process is redetermination by the Medicare Administrative ‘contractor (MAC). This involves requesting that the MAC, which processed the original claim, reevaluate the decision based on additional evidence, or arguments provided by the beneficiary.

Question 47

Mrs. Davis has Medicare Advantage and has a disagreement about a payment or service that does not involve a decision about whether the service is covered by Medicare. What is the most appropriate process for her to follow to resolve this disagreement?

Answer 47

Answer: File a grievance.

Explanation:

Grievances in a Medicare Advantage Plan are complaints that do not involve payment or denial of services. If Mrs. Davis has a complaint about the way a service was provided or other non-coverage issues, she should file a grievance with her plan.

Question 48

Mr. Smith has been denied coverage for a prescription drug under his Medicare Part D plan. He and his prescriber believe the drug is necessary for his treatment. What can Mr. Smith request to get access to this drug?

Answer 48

Answer: Exception

Explanation:

If a necessary drug isn’t covered under a Medicare Part D plan, the beneficiary or the prescriber can request an exception. An exception, if granted, would allow the plan to cover the drug. If the request is denied, Mr. Smith can appeal the decision.

Question 49

Mrs. Johnson’s Medicare advantage Plan has denied a service, stating it is not medically necessary. She believes this service is necessary for her care. What is her next best course of action?

Answer 49

Answer: File an appeal with her plan.

Explanation:

If Mrs. Johnson’s Medicare Advantage Plan denies coverage for a service, she believes is medically necessary, she should file an appeal with her plan. An appeal is formal way of asking the plan to review and change its decision about covering a service or medication.

Question 50

Mr. Garcia has Original Medicare and has just received a decision on his second level of appeal (reconsideration by a Qualified Independent Contractor). He disagrees with this decision. What is the next level of appeal available to him?

Answer 50

Answer: Request a hearing before an Administrative Law Judge.

Explanation:

The third level of appeal in the Original Medicare appeals process is a hearing before an Administrative Law Judge (ALJ). This is the correct next step if Mr. Garcia disagrees with the second-level appeal decision and if the amount in question meets a minimum threshold. This stage involves a hearing, which can be conducted by video-teleconference or telephone or based on a review of the written record. It’s important to remember that each level of appeal has specific procedural steps and deadlines that must be followed.