NORTH CAROLINA MEDICARE SUPPLEMENT EXAMINATION SET
2025 QUESTIONS WITH SOLUTIONS RATED A+
✔✔60 day Lifetime Hospital Reserve Benefit - ✔✔Reserve days may be used after pt
has been hospitalized for > 90days
-Exhaustible Benefit
-Will no longer be available once it's been used.
-Pays 100% less a daily copay of $682 equivalent of 50% of current deductible.
✔✔benefit period (Medicare) - ✔✔begins with the first day of hospitalization and ends
when the patient has been out of the hospital for 60 consecutive days.
✔✔Non-Exhaustible Benefit - ✔✔for each separate benefit period is 90 days with an
exhaustible 60 day lifetime reserve.
-Medicare no longer pays hospital expenses during that benefit period after lifetime
reserves are exhausted.
✔✔Inpatient Medicare Benefits - ✔✔-Hospitalization is prescribed by a physician to treat
acute illness or accident
-Level of care care only be received as an inpatient.
-Facility must be certified by CMS & licensed by state
-Utilization Review Committee must certify that treatment given in medically necessary
before claim is submitted.
✔✔PPS (Prospective Payment System) - ✔✔fixed payment scale/schedule based on
your DRG (diagnosis related group) which is assigned at admission.
✔✔DRG (Diagnosis Related Group Classification) - ✔✔-Patient is assigned to a
Diagnosis Related Group (DRG) upon admission & that is the scheduled benefit
payment that will be provided to the hospital regardless of the actual duration of
confinement
-Hospital must accept this benefit payment as payment in full for the time period
approved by the DRG (Approved Charges)
✔✔QIO (Quality Improvement Organization) - ✔✔A private organization composed of
practicing physicians and other health care professionals in each state that is paid by
the Centers for Medicare & Medicaid Services under contract to review the care
provided to Medicare beneficiaries.
✔✔Medicare & inpatient psychiatric care - ✔✔Part A will pay benefits for a max of 190
days for inpatient psych care. Lifetime Maximum.
✔✔What Medicare Part A covers - ✔✔-Semi-private room, Routine nursing services
-ICU, CCU & other special care units
-All meals including special diets
, -Drugs administered inpatient
-Blood transfusions after 3 pts deductible
-OR & recovery room charges
-Ancillary items charged by hospital e.g. dressings, casts
-Pathology reports, lab exams charged by hospital
-Hospital charges for anesthesia services
-Radiology charges by hospital including radiation therapy
-Rehab services of hospital incl. physical, occupational & speech therapy
-Ambulatory devices provided by hospital incl. crutches, wheelchairs
✔✔Medicare Part A does not cover - ✔✔-Hospital stays >150 days for first benefit
period or no longer than 90 days after using up lifetime reserve
-Private rooms unless medically necessary
-Physician's or surgeon's fees (Medicare Part B)
-Luxury or convenience items rented from hospital
-Private duty nursing
-Tests or exams conducted/ billed by 3rd party or similar hospital charges incurred on
outpatient basis.
-Inpatient psych care of > 190 days during lifetime
✔✔Skilled Nursing Facility (SNF) & Medicare - ✔✔Part A will cover if hospitalized at
least 3 days & is then admitted to SNF within 30 days of stay in order to maintain
continuum of care for same/ related condition.
-SNF must be certified by CMS and have 24h nurse on duty.
-Days 1-20 - Part A will pay all approve costs for first 20d of each benefit period
-Days 21 to 100 - Part A will pay all costs except for 12.5% (1/8) of current deductible as
copay.
-Over 100 days - No benefit will be provided for that benefit period.
✔✔Levels of Nursing Home Care - ✔✔Skilled
Intermediate
Custodial
Medicare only pays for skilled care
✔✔Home Health Care - ✔✔Individual must be confined to home & under care of
physician who has establish a necessary home health care plan.
-Prior hospitalization not required
-First dollar coverage (no deductible will apply)
-Providers must be approved by CMS
-Patient must be unable to leave house without assistance
✔✔Charges covered under Home Health Care - ✔✔-Part-time or intermittent skilled
nursing care ( Up to 8h per day for 21 consecutive days )
-Physical, occupational or speech therapy
-Medical social services
2025 QUESTIONS WITH SOLUTIONS RATED A+
✔✔60 day Lifetime Hospital Reserve Benefit - ✔✔Reserve days may be used after pt
has been hospitalized for > 90days
-Exhaustible Benefit
-Will no longer be available once it's been used.
-Pays 100% less a daily copay of $682 equivalent of 50% of current deductible.
✔✔benefit period (Medicare) - ✔✔begins with the first day of hospitalization and ends
when the patient has been out of the hospital for 60 consecutive days.
✔✔Non-Exhaustible Benefit - ✔✔for each separate benefit period is 90 days with an
exhaustible 60 day lifetime reserve.
-Medicare no longer pays hospital expenses during that benefit period after lifetime
reserves are exhausted.
✔✔Inpatient Medicare Benefits - ✔✔-Hospitalization is prescribed by a physician to treat
acute illness or accident
-Level of care care only be received as an inpatient.
-Facility must be certified by CMS & licensed by state
-Utilization Review Committee must certify that treatment given in medically necessary
before claim is submitted.
✔✔PPS (Prospective Payment System) - ✔✔fixed payment scale/schedule based on
your DRG (diagnosis related group) which is assigned at admission.
✔✔DRG (Diagnosis Related Group Classification) - ✔✔-Patient is assigned to a
Diagnosis Related Group (DRG) upon admission & that is the scheduled benefit
payment that will be provided to the hospital regardless of the actual duration of
confinement
-Hospital must accept this benefit payment as payment in full for the time period
approved by the DRG (Approved Charges)
✔✔QIO (Quality Improvement Organization) - ✔✔A private organization composed of
practicing physicians and other health care professionals in each state that is paid by
the Centers for Medicare & Medicaid Services under contract to review the care
provided to Medicare beneficiaries.
✔✔Medicare & inpatient psychiatric care - ✔✔Part A will pay benefits for a max of 190
days for inpatient psych care. Lifetime Maximum.
✔✔What Medicare Part A covers - ✔✔-Semi-private room, Routine nursing services
-ICU, CCU & other special care units
-All meals including special diets
, -Drugs administered inpatient
-Blood transfusions after 3 pts deductible
-OR & recovery room charges
-Ancillary items charged by hospital e.g. dressings, casts
-Pathology reports, lab exams charged by hospital
-Hospital charges for anesthesia services
-Radiology charges by hospital including radiation therapy
-Rehab services of hospital incl. physical, occupational & speech therapy
-Ambulatory devices provided by hospital incl. crutches, wheelchairs
✔✔Medicare Part A does not cover - ✔✔-Hospital stays >150 days for first benefit
period or no longer than 90 days after using up lifetime reserve
-Private rooms unless medically necessary
-Physician's or surgeon's fees (Medicare Part B)
-Luxury or convenience items rented from hospital
-Private duty nursing
-Tests or exams conducted/ billed by 3rd party or similar hospital charges incurred on
outpatient basis.
-Inpatient psych care of > 190 days during lifetime
✔✔Skilled Nursing Facility (SNF) & Medicare - ✔✔Part A will cover if hospitalized at
least 3 days & is then admitted to SNF within 30 days of stay in order to maintain
continuum of care for same/ related condition.
-SNF must be certified by CMS and have 24h nurse on duty.
-Days 1-20 - Part A will pay all approve costs for first 20d of each benefit period
-Days 21 to 100 - Part A will pay all costs except for 12.5% (1/8) of current deductible as
copay.
-Over 100 days - No benefit will be provided for that benefit period.
✔✔Levels of Nursing Home Care - ✔✔Skilled
Intermediate
Custodial
Medicare only pays for skilled care
✔✔Home Health Care - ✔✔Individual must be confined to home & under care of
physician who has establish a necessary home health care plan.
-Prior hospitalization not required
-First dollar coverage (no deductible will apply)
-Providers must be approved by CMS
-Patient must be unable to leave house without assistance
✔✔Charges covered under Home Health Care - ✔✔-Part-time or intermittent skilled
nursing care ( Up to 8h per day for 21 consecutive days )
-Physical, occupational or speech therapy
-Medical social services
