Medicare - Jan. 21 & 23 Flashcards
When were Medicare and Medicaid passed? (Q)
1965
What department of the federal government administers Medicare? (Q)
Medicare is administered by an agency within the Department of Health and Human Services (HHS called the Centers for Medicare and Medicaid Services, or CMS.
Who is automatically eligible for Medicare? (Q)
United States citizens and lawful residents are automatically eligible for Medicare if they’re over age 65 and have paid Social Security taxes for at least 40 calendar quarters, or 10 years. 42 U.S.C § 426.
Does the automatic Medicare eligibility apply if the person is still working or has other income?
Yes.
Who else is eligible for Medicare? (Q)
Some spouses and former spouses of eligible individuals are also eligible even if the spouse never worked, and some federal retirees are eligible regardless of age.
How may disabled individuals be eligible for Medicare? (Q)
Disabled individuals may be eligible for Medicare if they qualify for Social Security or federal railroad retirement benefits; have end-stage renal disease; or have ALS, also known as Lou Gehrig’s disease.
How are Medicare benefits broken down? (Q)
Medicare benefits are broken into Parts A, B, C, and D.
What does Part A of Medicare cover? (Q)
Part A covers inpatient care, like hospital stays, skilled-nursing-facility stays, hospice care, and some home-health services.
What does Part B of Medicare Cover? (Q)
Part B covers outpatient services, like outpatient hospital visits, doctor’s office visits, durable medical equipment, and ambulance services.
What don’t Parts A and B of Medicare cover? (Q)
Parts A and B don’t cover dental or vision services.
What is Part C of Medicare? (Q)
Part C is a managed-care alternative to Parts A and B that covers the same care plus sometimes dental and vision services.
What does Part D of Medicare cover? (Q)
Part D covers prescription drugs.
Which parts of Medicare are referred together as “Traditional Medicare”? (Q)
Traditional Medicare refers to Parts A and B. Originally, Medicare provided only Parts A and B.
What do Parts A and B of Medicare have in common? (Q)
Both parts are administered by the federal government and allow beneficiaries to choose any provider that accepts Medicare. Both parts may require beneficiaries to pay deductibles and to provide coinsurance for some services.
What is a deductible? (Q)
A deductible is an amount the beneficiary must pay before insurance will pay for services.
What is coinsurance? (Q)
Coinsurance is a percentage of a bill that the beneficiary pays even after meeting a deductible.
Is there a cap on the maximum amount that a beneficiary may owe for deductibles and coinsurance under Parts A and B? (Q)
No.
What is one significant difference between Parts A and B of Medicare? (Q)
One significant difference between these two parts is their premiums.
What is Part A’s premium? (Q)
For Part A, coverage is free for beneficiaries over 65 who’ve paid Social Security taxes for 40 quarters (no premium) and is available for a small premium to others.
What is part B’s premium? (Q)
For Part B, everyone must pay a premium. However, people with low income may qualify to have Medicaid cover their Part B premium.
What is Part C also known as? (Q)
Part C is known as Medicare Advantage.
How may a beneficiary of Medicare choose Part C? (Q)
A beneficiary may select Part C as an alternative to Parts A and B.
What happens when a beneficiary chooses Part C? (Q)
The beneficiary then chooses a private managed-care plan from several options, many of which are administered by health-maintenance organizations, or HMOs.
What are the downsides of HMOs? (Q)
HMOs frequently offer a limited provider network and require referrals from a primary-care manager to see specialists.
What do beneficiaries who choose Part C have to pay? (Q)
Part C plans may require beneficiaries to pay premiums, deductibles, and copays.
What are copays? (Q)
Copays are flat-fee amounts that a beneficiary contributes to a medical service.
What is the difference between copays in Part C as opposed to Parts A and B? (Q)
Unlike Parts A and B, Part C caps the maximum amount that a beneficiary is required to spend out of pocket.
What entity funds Medicare’s Part D? (Q)
The federal government funds Part D’s prescription-drug benefits.
What entity administers Part D’s prescription-drug benefits? (Q)
Private plans administer those benefits.
How can a beneficiary have Part D’s coverage? (Q)
A beneficiary may have Part D coverage included with some Part C plans or purchase it as an add-on to any Medicare coverage.
How may Medicare beneficiaries supplement their plans? (Q)
Medicare beneficiaries may also purchase supplemental private insurance, such as dental or vision insurance or a product called Medigap, which helps cover the unlimited out-of-pocket expenses under Parts A and B.
What reimbursement system do Parts A and B use? (Q)
Currently, Parts A and B use prospective-payment systems.
What is a prospective-payment system? (Q)
A prospective-payment system uses a preset amount for each medical service. If a provider accepts a Medicare patient, the provider agrees to accept reimbursement at that preset amount.
What are Medicare’s Part A preset reimbursement amounts for hospitals and other inpatient providers based on? (Q)
Medicare Part A’s preset reimbursement amounts for hospitals and other inpatient providers are based on which Diagnoses-Related Group, or DRG, applies to a patient’s particular diagnosis.
How may a preset amount for a diagnosis be adjusted? (Q)
The preset amount for a diagnosis may be adjusted to reflect a particular facility’s individual factors, with upward adjustments for hospitals that provide public services, like teaching hospitals or hospitals in underserved communities.
What did the Affordable Care Act (ACA) do to help Medicare benefits regarding quality of care? (Q)
The ACA created a value-based purchasing program tying Part A payments to quality in some ways. For instance, the act imposes financial penalties on hospitals that have high readmission rates for Medicare beneficiaries.
What are Part B’s preset reimbursement amounts for doctors based on? (Q)
Part B’s preset reimbursement amounts for doctors are based on a particular medical service’s current procedural terminology, or CPT, code.
How are CPT’s similar to DRG’s? (Q)
Like a DRG’s preset amounts, a CPT code’s preset amount may be adjusted for specific providers to account for a provider’s individual factors.
How are Part C’s managed-care plans reimbursed? (Q)
Part C’s managed-care plans are reimbursed a monthly amount for providing coverage to beneficiaries.
How is the monthly amount for Part C’s managed-care plans reimbursement set? (Q)
The monthly amount is set using a bidding system, with different financial risks and benefits for bids that are above and below a benchmark amount set by CMS.
How did the ACA account for care quality with respect to Part C? (Q)
To account for care quality, the Affordable Care Act implemented the Star Rating Program for Part C reimbursements. Among other things, if a health plan provides quality care as defined by the program’s metrics, the plan receives a bonus payment.
What is the Emergency Medical Treatment and Active Labor Act (EMTALA)? (Deliganis)
EMTALA covers medical facilities that accept medicare reimbursement and have emergency departments, must screen and stabilize emergency patients, need not provide full course of treatment (but no delays), need not provide free treatment (but can’t refuse based on payment)
