NORTH CAROLINA MEDICARE SUPPLEMENT EXAM SCRIPT
2025 QUESTIONS WITH SOLUTIONS RATED A+
✔✔Working-Employer Group Health Plan - ✔✔Less than 20 employees Medicare is
primary, more than 20 employees the group plan is primary. If group plan doesn't pay
total then Medicare pays secondary for covered services.
✔✔Prospective Payment System (PPS) - ✔✔Designed to have providers be more
efficient in delivering care. Hospitals paid predetermined rate for each Medicare
admission. Rate based on the patient DRG
✔✔Diagnosis Related Groups (DRGs) - ✔✔Each patient classified based on clinical
info. Hospital Paid flat rate regardless of services provided. Discourages over-treatment
and more efficient care.
✔✔Quality Improvement Organizaiton (QIO) - ✔✔Private firm used to help improve
services and control costs. One firm per state. Made up of doctors and health pros.
Main goal to improve quality of care for beneficiaries and protect integrity of Medicare
Trust Fund. Respond to complaints and appeals.
✔✔Utilization and Review Committee (URC) - ✔✔Purpose is to review all aspects of
care being submitted to Medicare for payment, such as admission, treatment, and
length of pay.
✔✔Medicare Administrative Contractor (MAC) - ✔✔Private firms contracted by
Medicare to process claims. One provider per region (handle several states) Also enroll
and train providers on Medicare.
✔✔Assignment - ✔✔Means provider has agreed to accept predetermined fee set by
Medicare as full payment for services rendered. Fee is called "Medicare Approved
Amount". Called participating providers.
✔✔Approved charges/charge limits - ✔✔If you use a non-participating provider, they
can charge 15% more than Medicare approved amount which beneficiary is responsible
for.
✔✔Medicare Conditional Payment (Subrogation) - ✔✔If Medicare makes conditional
payment to cover costs while beneficiary is settling a claim for something like workers
comp or liability insurance. If beneficiary later receives a settlement covering costs
they're required to pay Medicare back.
✔✔Inpatient Hospital Care (Benefit periods) - ✔✔Important for determining the benefits
a beneficiary is entitled to and portion of cost they're responsible for.
, ✔✔Inpatient Hospital Care (Benefit periods) - ✔✔Begins on the 1st day they're admitted
as an inpatient and ends 60 days after they have been discharged.
✔✔Inpatient Hospital Care (Days 1-60) - ✔✔Medicare pays the entire cost minus the
part A deductible
✔✔Non-exhaustible benefit - ✔✔No matter how many benefit periods they have
Medicare always pays cost in first 60 days.
✔✔Inpatient Hospital Care (Days 61-90) - ✔✔Medicare pays most of the cost (75%)
and beneficiary pays a daily copayment (Non-exhaustible)
✔✔Daily copayment (coinsurance) - ✔✔75-25 payment split
✔✔Inpatient Hospital Care (Days 91-150 (lifetime reserve days)) - ✔✔Medicare still
pays most of the cost (50%) but "ben" responsible for larger coinsurance payment.
Given 60 lifetime days it does exhaust
✔✔Exhaustible benefit - ✔✔Once beneficiary uses up 60 lifetime days Medicare no
longer pays beyond the 90th day
✔✔Covered expenses - ✔✔Semi-private room, meals, general nursing, hospital
services and supplies (X-rays, lab tests, rx drugs administered by hospital, room
charges, rehab)
✔✔Exclusions - ✔✔Private room unless deemed necessary or non medical expenses
(TV), long-term/custodial care, private nursing, cosmetic surgery, experimental
medicine, dental, hearing, or vision
✔✔Skilled Nursing Facility (SNF) care - ✔✔Facility provides round the clock medical
and rehab care by licensed nurses and other trained professionals by order of physician
✔✔Skilled Nursing Facility (SNF) care (Benefit periods) - ✔✔Begins on 1st day of
admittance
✔✔Skilled Nursing Facility (Days 1-20) - ✔✔Medicare pays the entire cost
✔✔Skilled Nursing Facility (Days 21-100) - ✔✔Medicare pays most of the cost and
beneficiary has coinsurance payment higher than what it is for hospital inpatient fee
✔✔Skilled Nursing Facility (SNF) care (Covered services) - ✔✔Semi-private room,
meals, nursing, rehab, meds admin by facility, misc medical items
2025 QUESTIONS WITH SOLUTIONS RATED A+
✔✔Working-Employer Group Health Plan - ✔✔Less than 20 employees Medicare is
primary, more than 20 employees the group plan is primary. If group plan doesn't pay
total then Medicare pays secondary for covered services.
✔✔Prospective Payment System (PPS) - ✔✔Designed to have providers be more
efficient in delivering care. Hospitals paid predetermined rate for each Medicare
admission. Rate based on the patient DRG
✔✔Diagnosis Related Groups (DRGs) - ✔✔Each patient classified based on clinical
info. Hospital Paid flat rate regardless of services provided. Discourages over-treatment
and more efficient care.
✔✔Quality Improvement Organizaiton (QIO) - ✔✔Private firm used to help improve
services and control costs. One firm per state. Made up of doctors and health pros.
Main goal to improve quality of care for beneficiaries and protect integrity of Medicare
Trust Fund. Respond to complaints and appeals.
✔✔Utilization and Review Committee (URC) - ✔✔Purpose is to review all aspects of
care being submitted to Medicare for payment, such as admission, treatment, and
length of pay.
✔✔Medicare Administrative Contractor (MAC) - ✔✔Private firms contracted by
Medicare to process claims. One provider per region (handle several states) Also enroll
and train providers on Medicare.
✔✔Assignment - ✔✔Means provider has agreed to accept predetermined fee set by
Medicare as full payment for services rendered. Fee is called "Medicare Approved
Amount". Called participating providers.
✔✔Approved charges/charge limits - ✔✔If you use a non-participating provider, they
can charge 15% more than Medicare approved amount which beneficiary is responsible
for.
✔✔Medicare Conditional Payment (Subrogation) - ✔✔If Medicare makes conditional
payment to cover costs while beneficiary is settling a claim for something like workers
comp or liability insurance. If beneficiary later receives a settlement covering costs
they're required to pay Medicare back.
✔✔Inpatient Hospital Care (Benefit periods) - ✔✔Important for determining the benefits
a beneficiary is entitled to and portion of cost they're responsible for.
, ✔✔Inpatient Hospital Care (Benefit periods) - ✔✔Begins on the 1st day they're admitted
as an inpatient and ends 60 days after they have been discharged.
✔✔Inpatient Hospital Care (Days 1-60) - ✔✔Medicare pays the entire cost minus the
part A deductible
✔✔Non-exhaustible benefit - ✔✔No matter how many benefit periods they have
Medicare always pays cost in first 60 days.
✔✔Inpatient Hospital Care (Days 61-90) - ✔✔Medicare pays most of the cost (75%)
and beneficiary pays a daily copayment (Non-exhaustible)
✔✔Daily copayment (coinsurance) - ✔✔75-25 payment split
✔✔Inpatient Hospital Care (Days 91-150 (lifetime reserve days)) - ✔✔Medicare still
pays most of the cost (50%) but "ben" responsible for larger coinsurance payment.
Given 60 lifetime days it does exhaust
✔✔Exhaustible benefit - ✔✔Once beneficiary uses up 60 lifetime days Medicare no
longer pays beyond the 90th day
✔✔Covered expenses - ✔✔Semi-private room, meals, general nursing, hospital
services and supplies (X-rays, lab tests, rx drugs administered by hospital, room
charges, rehab)
✔✔Exclusions - ✔✔Private room unless deemed necessary or non medical expenses
(TV), long-term/custodial care, private nursing, cosmetic surgery, experimental
medicine, dental, hearing, or vision
✔✔Skilled Nursing Facility (SNF) care - ✔✔Facility provides round the clock medical
and rehab care by licensed nurses and other trained professionals by order of physician
✔✔Skilled Nursing Facility (SNF) care (Benefit periods) - ✔✔Begins on 1st day of
admittance
✔✔Skilled Nursing Facility (Days 1-20) - ✔✔Medicare pays the entire cost
✔✔Skilled Nursing Facility (Days 21-100) - ✔✔Medicare pays most of the cost and
beneficiary has coinsurance payment higher than what it is for hospital inpatient fee
✔✔Skilled Nursing Facility (SNF) care (Covered services) - ✔✔Semi-private room,
meals, nursing, rehab, meds admin by facility, misc medical items
