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Medicare Facts
Final Review
| Question | Answer |
|---|---|
| Who is generally eligible for Medicare? | Primarily for ages 65+ who have paid (or are spouse of payee) into the plan for 40 quarters or twenty years. |
| Other persons eligible for Medicare are? | Retired railroad workers; those currently receiving SS benefits; persons with end-stage (renal) kidney disease |
| When was Medicare enacted? | In 1965, under the SS Act. It is a federal insurance program. |
| Define Medicare Part A? | automatic when eligibility and deductible met; covers hospital (inpatient) costs; hospice; limited nursing home stays; home health |
| Define Medicare Part B? | (optional) premiums, deductibles, and co-ins. are required; covers physician costs; outpatient services; DME (Durable Medical Equipment) and medical supplies |
| Define Medicare Part C? | (HMO type coverage) called Medicare Advantage; Must be enrolled under part A & B to participate. |
| Define Medicare Part D? | (optional) Covers approved pharmaceuticals |
| Assignment of Benefits | when a pt gives written authorization for reimbursement to the physician for billed charges |
| Coordination of Benefits | one insurance plan working with another to determine how much each plan pays (who pays first?) |
| Insured | The person who is covered by the benefits plan |
| Dependent | Spouse or child covered under the insured's benefits plan |
| Fee Schedule | Amount that will be paid by the insurance plan for each procedure or service is based on this? (Dr.'s list of customary charges) |
| Medicaid | Government sponsored program that provides health benefits to low income or indigent persons. |
| Workers Compensation | Expenses that result form work-related illness/injuries are covered by this. |
| (EOB)Explanation of Benefits | Statement issued to both provider & Pt. that details a payment that has been made by the plan |
| Where could a patient find his/her co-pay, deductible, allowable amount and amount paid to the provider for health services? | On the Explanation of Benefits (EOB) statement. |
| Pre-existing condition | a disease diagnosed before the effective date of coverage by the insurance plan |
| Deductible | Amount of eligible charges each pt. must pay each calendar year before the plan begins to pay benefits. |
| Precertification | Process of determining whether a service or procedure will be covered by the insurance provider |
| What is CHAMPVA? | Plan under which medical bills of spouses/children of vets with total permanent, service-connected disabilities are covered. |
| Capitation | Making a payment to a provider based on a "fixed amount" per enrollee assigned to that provider regardless of services provided. |
| HMO - Health Maintenance Organization | A group of physicians who have a contract to provide services to participating pts. for a pre-determined fee. |
| QIO - Quality Improvement Organization | A group of physicians who review cases for appropriateness of hospitalizations & discharges (are visits necessary, cost effective?) |
| Usual, customary and reasonable | Database or list of charges for each procedure; indicates the charge by a majority of physicians in a geographic area. |
| Premium | Amount paid by an individual to purchase benefits of a health insurance policy. |
| PCP - Primary Care Physician | A general practioner who oversees pts. in an HMO or PPO. |
| Exclusion | A condition or circumstance for which the health insurance policy will not provide benefits. |
| Disability Income Insurance | Insurance coverage that provides a specific monthly or weekly income when an individual becomes unable to work because of illness/injury. |
| Co-payment | Amount of money owed by insured to the provider at the time of service is called this |
| Birthday rule | Determination of the primary carrier is according to birth month when a dependent child is covered by benefit plans of both parents. |
| DRG - Diagnosis Related Groups | Hospital payment system that catagorizes pts. by diagnosis/treatment. |
| UCR payment basis | Usual, customary, and reasonable; What a majority of physicians in a specific geographic area charge for procedures/services rendered |
| Participating Provider | If Medicare sends a check to a physician's office he/she is this type of provider? |
Created by:
cchouinard
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