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Insurance > Medicare > Flashcards

Medicare Flashcards

1
Q

Medicare Part A

A

Hospital Insurance

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2
Q

Medicare Part B

A

Medical Insurance (Doctor’s coverage)

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3
Q

Medicare Part C

A

Medicare Advantage

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4
Q

Medicare Part D

A

Prescription Drug Plan

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5
Q

Medicare Part that is premium-free

A

Part A

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6
Q

Medicare Part that always has premium unless insured is elligible for Medicare Savings Program

A

Part B

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7
Q

Medicare Part(s) that could or could not have a premium

A

Parts C & D

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8
Q

“Original or Traditional” Medicare Parts

A

Parts A & B

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9
Q

Medicare ellgibility begins when

A

3 months prior to insured’s 65th birthday

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10
Q

Benefits for those who enroll during the initial enrollment period begin when?

A

1st day of the month of their 65th birthday, unless their birthday is on the first, in which case benefits start on the 1st of the month prior to their birthday

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11
Q

T/F Individuals who do not enroll in the 3 month period before their 65th birthday will be delayed in receiving benefits

A

True

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12
Q

An individual can qualify for Medicare before they are 65 if they are currently receiving SS disability or Railroad Board disability benefits and havebeen for how long?

A

24 months

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13
Q

What disease allows for Medicare Part A benefits beginning with the 1st month of the disability?

A

Lou Gehrig’s Disease (ALS)

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14
Q

Kidney dialysis/kidney transplants are covered by Parts A & B, before age 65, for how long?

A

Until twelve months after end of kindey dialysis or 36 months after a kidney transplant

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15
Q

What time frame is the initial enrollment period?

A

3 months prior to month of 65th birthday, birthday month, and the 3 months after

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16
Q

When is the general enrollment period?

A

January 1st-March 31st annually

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17
Q

When does coverage start for those who enroll during the general enrollment period?

A

July 1st of that year

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18
Q

For a group health plan to be considered “elligible” for the insured to delay benefits, how many employees must the group plan cover?

A

20+

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19
Q

T/F A group healthplan is only considered “elligible” for delaying of Medicare benefits if the group policy would qualify for COBRA

A

True

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20
Q

What is the time frame for the Special Enrollment Period?

A

8 months after elligible insured ceases being covered by the group plan that allowed him or her to delay Medicare benefits

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21
Q

If insured is covered by both a group policy and Medicare, when will Medicare be the primary coverage?

A

Only when there are less than 20 employees covered by the group policy. If there are more than 20 then Medicare becomes secondary coverage

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22
Q

What does DRG stand for?

A

Diagnosis-related group

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23
Q

How many major diagnostic categories does Medicare divide all sicknesses and injuries into?

A

23

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24
Q

How many sub-groups does medicare divide the major diagnostic categories into?

A

999

25
Q

When appealed, a negative decision by a QIO will generally be reviewed within how long?

A

72 hours (this is referred to as immediate review or expedited appeal)

26
Q

Who is the Medicare Administrative Contractor (MAC) in North Carolina?

A

Palmetto Government Benefits Administrators (Palmetto GBA)

27
Q

What does MSN stand for?

A

Medicare Summary Notice

28
Q

Which parts of Medicare are MAC’s responsible for reimburing to the care provider?

A

Parts A & B

29
Q

Who issues the MSN to the Medicare beneficiary?

A

The Medicare Administrative Contractor

30
Q

In which cases is Medicare the secondary payer rather than the primary?

A

Workers Comp Claims

No-Fault or Liability Insurance

Black Lung Benefits

Beneficiary is insured by a group policy with at least 20 covered employees (and teh policy qualifies for COBRA)

31
Q

T/F Medicare eligible persons traveling outside the United States can always be reimbursed for medical expenses incurred while outside the country

A

False. Medicare almost never covers expenses incurred outside the US. There are only 3 exceptions:

  • When the insured lives closer to a Mexican or Candian medical facility and has a medical emergeny
  • When the insured lives closer to a Mexican or Canadian medical facility and it is certified by Medicare then they can be reimbursed for non-emergency charges as well
  • When the insured is traveling by direct route to or from Alaska, through Canada
32
Q

What is the tax rate for Medicare Hospital Insurance (Part A)?

A

1.45% for employers and 1.45% for employees (self-employeed persons pay the full 2.9% tax)

33
Q

How old must Social-Security eligible spouse be in order for non-eligible spouse to receive premium free Part A coverage?

A

62

34
Q

How many years must a couple stay married before divorcing in order for the ex-spouse who is ineligible for SS benefits to receive premium-free Part A coverage?

A

10 years

35
Q

Individuals who do not qualify for premium-free Part A coverage can purchase coverage if they have lived in the US for at least the previous ___ years

A

5

36
Q

2014 Part A premium for non-qualified enrollees who have accumulated 30-39 quarters of Medicare covered employment

A

$234/month

37
Q

2014 Part A premium for non-qualified enrollees who have accumulated fewer than 30 quarters of Medicare covered employment

A

$426/month

38
Q

penalty rate for those who are required to pay premiums for Part A and don’t enroll within 12 months of the end of the initial enrollment period

A

10% (continues based on the premium at the time as long as they continue having to pay premiums)

39
Q

Types of medically necessary care for which Part A provides coverage

A
  • inpatient hospital care (including psychiatric hospital)
  • inpatient care in a skilled nursing facility/unit following a hospital stay
  • home health care
  • hospice care for the terminally ill
40
Q

What are the three “Spell of Illness” day groups

A
  1. 1-60 days with deductible
  2. 61-90 days with daily co-insurance
  3. 91-150 days with a higher daily coinsurance
41
Q

When does a benefit period for Part A begin and end?

A

1st day of Medicare-covered hospital services-60 consecutive days after discharge from last services available

42
Q

2014 Part A Benefit Period Deductible

A

$1,216 for each new benefit period

43
Q

When are Part A deductibles collected?

A

AFTER services are rendered. Beneficiary CANNOT be charged upon entrance to hospital

44
Q

Part A Coinsurance for days 61-90 of a benefit period

A

$304/day

45
Q

Can Spell-of-illness days 91-150 be replenished?

A

No

46
Q

Part A Coinsurance for days 91-150 of benefit period

A

$608/day

47
Q

Annual blood transfusion deductible (how many pints before coverage starts)

A

3 pints

48
Q

Part A exclusions

A
  • physician charges
  • private duty nurses
  • personal convenience items (television, phone, etc.)
49
Q

Lifetime max number of days of psychiatric hospital or unit of hospital coverage by Part A

A

190 days

50
Q

When qualified, how many days of Skilled Nursing Facility Care will a beneficiary have fully covered by Part A?

A

Days 1-20

51
Q

Part A coinsurance for Skilled Nursing Facility services after first 20 days

A

$152 per day for days 21-100

52
Q

Part A Coinsurance amounts for spell-of-ilness days 61-90 are what percentage of the benefit period deductible?

A

25% (1/4)

53
Q

Part A Coinsurance amounts for spell-of-illness days 91-150 (lifetime reserve days) are what percentage of the benefit period deductible

A

50% (1/2)

54
Q

Part A coinsurance amounts for Skilled Nursing Facility servicese are what percentage of the benefit period deductible?

A

12.5% (1/8)

55
Q

Medicare beneficiary must have physician-certified life-expectancy of less than how many months in order for Part A to cover Hospice Services?

A

6 months or less

56
Q

Coinsurance for pain relief/symptom management drugs under Part A (for hospice)

A

$5 or 5%, whichever is less

57
Q

Part A Respite coverage coinsurance

A

5%

58
Q

How many days per benefit period will Part A pay for (the majority of) respite?

A

5 days

59
Q

What is the coinsurance the beneficiary must pay for Durable Medical Equipment under Part A (DMEs)

A

20%

Insurance (4 decks)

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