,1. Larry Miller – Part A Deductibles
Question:
Larry Miller is an Original Medicare beneficiary with Parts A and B coverage. Larry
is admitted to Good Care Hospital in January with pneumonia and stays for three
days before being discharged. Six months later in July, Larry takes a bad fall and is
admitted to Good Care Hospital with a broken leg. After emergency surgery to
repair his broken leg, Larry is hospitalized for a week before being discharged
home. In December, Larry is admitted to Mount Wellness Hospital once again
with a serious case of the flu. For how many Part A deductibles will Larry be
responsible for?
A. One Part A deductible
B. Two Part A deductibles
C. Larry will be responsible for three Part A deductibles.
D. Larry will not have to pay any Part A deductibles.
Correct Answer: C
Expert Rationale:
The Medicare Part A hospital deductible applies to each benefit period, not
annually. A benefit period begins the day a beneficiary is admitted as an inpatient
and ends when they have not received inpatient care for 60 consecutive days.
Larry's three hospitalizations (January, July, December) each represent separate
benefit periods because they are separated by more than 60 days. Therefore, he
owes three separate Part A deductibles.
2. Kevin Birch – Skilled Nursing Facility Appeal
,Question:
Kevin Birch enrolled in Original Medicare (Parts A and B). Mr. Birch has been
receiving rehabilitation services in a skilled nursing facility. He calls you to say that
he has just received a notice that Medicare will no longer cover his stay and he
still cannot walk properly. He thinks they are ending his services too soon. What
do you tell him?
A. He should accept the decision and prepare for discharge immediately.
B. He should follow the directions on the notice to file a fast appeal. Mr. Birch
should file it by noon of the calendar day following receipt of the provider's notice
of termination of services.
C. He should contact his physician to write a new order for continued stay.
D. He should file a standard appeal within 60 days of discharge.
Correct Answer: B
Expert Rationale:
When a skilled nursing facility (SNF) issues a Notice of Non-Coverage (NNC)
stating Medicare will no longer cover services, beneficiaries have the right to an
expedited (fast) appeal through the Quality Improvement Organization (QIO). The
appeal must be filed by noon the day after receiving the notice. This is distinct
from a standard appeal (D) and does not require a new physician order (C).
Accepting the decision (A) would forfeit appeal rights.
3. Mr. Ray – Prescription Drug Coverage
Question:
Mr. Ray would like drug coverage but does not want to be enrolled in a Medicare
Advantage plan. What should you tell him?
, A. He must enroll in a Medicare Advantage plan to get drug coverage.
B. Mr. Ray can enroll in a stand-alone prescription drug plan and continue to be
covered for Part A and Part B services through Original Fee-for-Service Medicare.
C. He can only get drug coverage through his employer's plan.
D. He should purchase a Medigap plan that includes drug coverage.
Correct Answer: B
Expert Rationale:
Medicare beneficiaries in Original Medicare can enroll in a stand-alone
Prescription Drug Plan (PDP) to obtain Part D coverage without joining a Medicare
Advantage plan. Option A is incorrect because MA enrollment is not required for
drug coverage. Option C is incorrect because employer coverage is not the only
avenue. Option D is incorrect because Medigap plans sold today cannot include
prescription drug coverage (this ended in 2006).
4. Mrs. Sanders – Medicare Eligibility
Question:
Mrs. Sanders will be 65 soon, has been a citizen for twelve years, has been
employed full-time, and paid taxes during that entire period. She is concerned
that she will not qualify for coverage under Part A because she was not born in
the United States. What should you tell her?
A. She must have been born in the United States to qualify for Medicare.
B. Most individuals who are citizens and age 65 or over are covered under Part A
by virtue of having paid Medicare taxes while working, though some may be
covered as a result of paying monthly premiums.
C. She must wait an additional five years after becoming a citizen before
qualifying for Medicare.
Question:
Larry Miller is an Original Medicare beneficiary with Parts A and B coverage. Larry
is admitted to Good Care Hospital in January with pneumonia and stays for three
days before being discharged. Six months later in July, Larry takes a bad fall and is
admitted to Good Care Hospital with a broken leg. After emergency surgery to
repair his broken leg, Larry is hospitalized for a week before being discharged
home. In December, Larry is admitted to Mount Wellness Hospital once again
with a serious case of the flu. For how many Part A deductibles will Larry be
responsible for?
A. One Part A deductible
B. Two Part A deductibles
C. Larry will be responsible for three Part A deductibles.
D. Larry will not have to pay any Part A deductibles.
Correct Answer: C
Expert Rationale:
The Medicare Part A hospital deductible applies to each benefit period, not
annually. A benefit period begins the day a beneficiary is admitted as an inpatient
and ends when they have not received inpatient care for 60 consecutive days.
Larry's three hospitalizations (January, July, December) each represent separate
benefit periods because they are separated by more than 60 days. Therefore, he
owes three separate Part A deductibles.
2. Kevin Birch – Skilled Nursing Facility Appeal
,Question:
Kevin Birch enrolled in Original Medicare (Parts A and B). Mr. Birch has been
receiving rehabilitation services in a skilled nursing facility. He calls you to say that
he has just received a notice that Medicare will no longer cover his stay and he
still cannot walk properly. He thinks they are ending his services too soon. What
do you tell him?
A. He should accept the decision and prepare for discharge immediately.
B. He should follow the directions on the notice to file a fast appeal. Mr. Birch
should file it by noon of the calendar day following receipt of the provider's notice
of termination of services.
C. He should contact his physician to write a new order for continued stay.
D. He should file a standard appeal within 60 days of discharge.
Correct Answer: B
Expert Rationale:
When a skilled nursing facility (SNF) issues a Notice of Non-Coverage (NNC)
stating Medicare will no longer cover services, beneficiaries have the right to an
expedited (fast) appeal through the Quality Improvement Organization (QIO). The
appeal must be filed by noon the day after receiving the notice. This is distinct
from a standard appeal (D) and does not require a new physician order (C).
Accepting the decision (A) would forfeit appeal rights.
3. Mr. Ray – Prescription Drug Coverage
Question:
Mr. Ray would like drug coverage but does not want to be enrolled in a Medicare
Advantage plan. What should you tell him?
, A. He must enroll in a Medicare Advantage plan to get drug coverage.
B. Mr. Ray can enroll in a stand-alone prescription drug plan and continue to be
covered for Part A and Part B services through Original Fee-for-Service Medicare.
C. He can only get drug coverage through his employer's plan.
D. He should purchase a Medigap plan that includes drug coverage.
Correct Answer: B
Expert Rationale:
Medicare beneficiaries in Original Medicare can enroll in a stand-alone
Prescription Drug Plan (PDP) to obtain Part D coverage without joining a Medicare
Advantage plan. Option A is incorrect because MA enrollment is not required for
drug coverage. Option C is incorrect because employer coverage is not the only
avenue. Option D is incorrect because Medigap plans sold today cannot include
prescription drug coverage (this ended in 2006).
4. Mrs. Sanders – Medicare Eligibility
Question:
Mrs. Sanders will be 65 soon, has been a citizen for twelve years, has been
employed full-time, and paid taxes during that entire period. She is concerned
that she will not qualify for coverage under Part A because she was not born in
the United States. What should you tell her?
A. She must have been born in the United States to qualify for Medicare.
B. Most individuals who are citizens and age 65 or over are covered under Part A
by virtue of having paid Medicare taxes while working, though some may be
covered as a result of paying monthly premiums.
C. She must wait an additional five years after becoming a citizen before
qualifying for Medicare.
