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Mod 2A UHI Ch. 14


Medicare Part A Reimburses institutional providers for inpatient hospital, critical care, skilled nursing facility, hospice, some home health care
Medicare Part B Reimburses institutional providers for outpatient services, doctors services, outpatient hospital care, durable medical equipment and some services not covered by part A
Medicare Advantage (Part C) Includes managed care and private fee-for-service plans that provided contracted care to Medicare patients; monthly premiums.
Medicare Prescription Drug (Part D) Adds prescription drug coverage to the original Medicare plans, fee-for service- cost plans, and medical savings account plans.
Medicare Eligibility Individual or spouse employed 10 years in Medicare covered employment, minimum of 65 years, must be a citizen or permanent resident of the U.S.
Medicare Eligibility Information Obtain through EDI (electronic data interchange)
Medicare Enrollment Individuals are enrolled automatically or apply for coverage.
Automatic Enrollment 3 months before 65th b-day or 24th month of disability, individuals sent enrollment packet.
General Enrollment Period (GEP) January 1 through March 31
Qualified Medicare beneficiary program (QMBP) Helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles and coinsurance amounts.
Specified Low-Income Medicare Beneficiary (SLMB) Helps low income individuals by requiring states to pay their Medicare Part B premiums.
Qualifying Individual (Q1-1) Helps low income individuals by requiring states to pay their Medicare Part B premiums.
Qualified Disabled Working Individual (QDWI) Helps individuals who received SS and Medicare because of disability, but who lost their SS benefits and free Medicare Part A because of returning to work and earnings exceed the limit allowed by requiring states to pay their Medicare Part A premium.
Benefit Period Spell of illness-begins with first day of hospitalization and ends when patient has been out of the hospital for 60 consecutive days.
Home Health Services Must be physician prescribed
Hospice Care All terminally ill patients qualify; administered program of coordinated inpatient and outpatient services for terminally ill patients and their families.
Respite Care Temporary hospitalization of a terminally ill patient for the purpose of providing relief for the caregiver.
Medicare Part D Coverage Offers Rx drug coverage to all Medicare patients; may help lower the costs and help protect against higher costs in future; optional coverage; monthly premium
PACE (Programs of All-Inclusive Care for the Elderly) Combine medical, social and long-term care services for frail people who live and receive health care in the community.
PACE Elgibility 55 years old; resident of service area covered; able to live safely in community; certified as eligible for nursing home care by state agency.
Medigap Supplemental program to Medicare
Participating Provider Agreement Agreement to accept assignment on all Medicare claims.
Participating Provider Agreement Includes: Special message printed on all unassigned Medicare Summary Notice forms mailed to patients; reminds patients of the reduction in out-of-pocket expenses if they use PAR's
Nonparticipating Provider Fees are restricted to not more than the limiting charge; collections are restricted to only the deductible and coinsurance.
Surgical Disclosure Patients must sign for all non-assigned surgical fees over $500.
Limiting Charge Non Par who do not accept assignment on Medicare Claims are subject to a limit on what can be charged to beneficiaries for covered services.
Accepting Assignment Non Pars who agree to accept assignment on a claim will be reimbursed the Medicare-allowed fee; may collect any unpaid deductible and the 20$ coinsurance determined from the MPFS
Who must accept assignment Nursing practitioners, labs and x-rays
Elective Surgery Patient chosen surgery; non-emergency; surgical disclosure notice required.
Advance Beneficiary Notice Written document provided to a Medicare beneficiary by a supplier or physician prior to service being rendered indicating that services is unlikely to be reimbursed by Medicare and reason for denial is anticipated; personal payment guarantee agreement req
Experimental and Investigational procedures Not covered by Medicare; provider must refund any payment received from a patient for a service denied by Medicare as investigational.
Medicare as Primary Payer Patient is also covered by Cobra or Tricare; under 65 with disability and not covered by ESRD; under 65, has ESRD but been eligible for Medicare for more than 30 days.
Medicare Secondary Payer Patient has EGHP, has a third party liability policy (auto ins, homeowners ins, etc), workers comp, VA, Federal Black Lung program.
EGHPESRD Employee Group Health Plan
Medicare Summary Notice Monthly statement that clearly lists health insurance claims information; like an EOB
Medicare Administrative Contractor The regional MAC for traditional Medicare claims and is selected by CMS through a competive bidding process; where all claims go
DME (Durable Medical Equipment) Claims Must be sent to one of four regional Medicare administrative contractors in the country; 3 in U.S. one overseas
Claim Filing Deadline December 31st of the year following the date on which services are provided or if service between Oct 1st and Dec 31st deadline is extended to Dec 31st of the second year.
Claims Instructions Law says that all Medicare claims must be filed using optical scanning guidelines.
Medicare-Medicaid Crossover Provides Medicare and Medicaid coverage; Medicare is secondary.
Roster Billing Enables Medicare beneficiaries to partake in mass pneumococcal pneumonia virus and influenza virus vaccination programs.
Created by: ROSSMIBOA
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