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MEDICARE

LESSON 2 MEDICARE AND MADICAID

QuestionAnswer
EXPLAIN THE DIFFERENT PARTS OF MEDICARE AND WHAT THEY COVER. Medicare Part A: hospital insurance. Part B: medical insurance that covers physician services. Part C: expanded benefits for HMO's and PPO's, Part D: Rx. drugs
WHO IS ELIGIBLE FOR MEDICARE BENEFITS? Individuals 65 and older, people with disabilities. People who became disable before age 18. and those with end stage renal disease.
WHAT DOES "ACCEPTING ASSIGNMENT" MEAN WITH MEDICARE? A provider who has agreed to accept the allowed charge of a rendered service as payment in full.
WHAT DOES IT MEAN WHEN THE PHYSICIAN IS A "NONPARTICIPATING PHYSICIAN?" A non participating physician is one that chooses not to participate in a Medicare Plan.
WHEN A MEDICARE PART A BENEFICIARY IS HOSPITALIZED, WHAT WILL THEY HAVE TO PAY? Deductible for days 1-60. co-pay for days 61-90
WHAT WAS MEDICARE PART A DEDUCTIBLE I N 2007? Medicare Part A deductible for all Medicare beneficiaries is $992 days 1-60
TO QUALIFY FOR MEDICARE, A DISABLED ADULT MUST HAVE BEEN RECEIVING SOCIAL SECURITY DISABILITY (SSD) BENEFITS FOR HOW LONG? For two years.
HOW LONG IS EACH BENEFIT PERIOD? A benefit period begins. when the patient goes to a hospital or a skilled nursing facility. The benefit period ends when you have not received any inpatient hospital care for 60 days in a row.
HOW IS THE MONTHLY PREMIUM FOR MEDICARE PART B DETERMINED? Medicare uses the modified adjusted gross income reported on your IRS tax return from two years ago (the most recent tax return info.)
AFTER A MEDICARE PART B BENEFICIARY PAYS THE DEDUCTIBLE, WHAT AMOUNT WILL MEDICARE PAY? Medicare will pay 80% and the patient will pay 20%
WHAT IS THE GOAL OF MEDICAID MANAGED CARE? To reduce Medicaid Program costs and better manage utilization of health services. improvement in health plan performance, healthcare quality, and outcomes.
WHO PAYS FOR MEDICAID? The federal and state government.
WHICH ORGANIZATION IS RESPONSIBLE FOR DETERMINING THE TYPE, AMOUNT, AND SCOPE OF SERVICES COVERED BY MEDICAID? Each state government.
WHAT ARE THE THREE GROUPS WHO ARE ELIGIBLE FOR MEDICAID? The categorically needy, the medically needy; and special groups. (pregnant women)
WHO DETERMINES THE ELIGIBILITY FOR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)? The county
THE EPSDT PROGRAM INCLUDES COVERAGE FOR CHILDREN YOUNGER THAN? ---- Children younger than age 21
HOW OFTEN SHOULD THE ELIGIBILITY BE CHECKED FOR A MEDICAID BENEFICIARY? Patient's eligibility should be checked each time they make an appointment and before they see the physician. (Every visit)
WHAT IS THE TIME LIMIT A MEDICAID CLAIM MUST BE FILED BY? within 95 days from discharge from hospital or date of service.
WHAT IS THE DEADLINE TO APPEAL A DENIED CLAIM? 180 days
WHEN FILING A CLAIM FOR A NEWBORN BABY BOY, FOR MOTHER SALLY SMITH, HOW SHOULD THE NAME BE LISTED ON THE CLAIM? The name field of the claim form should state Boy Sally Smith.
Created by: Lizbeth Romo