NC Medicare Supplement & Long Term Care Insurance Licensing Exam Questions With Correct Answers

Medicare - Answer Health insurance for those over age 65, people under 65 with certain disabilities & those with ESRD (end stage renal disease - permanent kidney failure requiring dialysis or kidney transplant) CMS - Answer Centers for Medicare and Medicaid Services administers the Medicare program. Social Security Administration handles most of the enrollment & plays a role in claims appeal process. MAC - Answer Medicare Administrative Contractor - company contracted to administer Part A & Part B claims. Medicare Part A - Answer -hospital coverage -no premium requirements for those with 40 "work credits" of FICA or Self Employment tax credits. -Those who don't qualify can voluntarily participate by paying a monthly premium Medicare Part B - Answer The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. -Has a monthly premium of $135.50 in 2019 which is deducted from SS check. -Part B enrollment is optional. You can reject Part B by signing a rejection form. Medicare Part C - Answer Medicare Advantage Plans that are offered through private insurance companies that provide both hospital and physician coverage and possible prescriptions - financed by Social Security and monthly premiums Medicare Eligibility - Answer -Over age 65 who have earned 40 "work credits" in order to receive premium free part A benefits -Permanently disabled prior to age 65 for at least 24 months -ESRD or kidney disease requiring dialysis or kidney transplant Medicare enrollment requirements - Answer Part A & B are automatically conducted by SSA when individual age 65+ enrolls for their Social Security retirement benefits Initial Enrollment Period - Answer 7 month period straddling 3 months before and ends 3 months after the individual turns 65, including the birthday month. -If enrollment is during the 3 mos prior to 65th birthday, coverage begins on 1st day of 65th birthday month -If enrollment is during or after 65th birthday month, coverage begins on 1st day of month after enrollment General Enrollment Period - Answer Medicare enrollment period - January 1st through March 31st annually. -Coverage begins July 1st of that year -Monthly premium for part B may go up 10% for each full 12 month period that you're eligible but didn't sign up. Special Enrollment Period - Answer Individual can enroll at 8 months beginning with the month employment ends or when group coverage ends whichever is earlier without subject to late enrollment surcharge Medicare as a secondary or primary payer - Answer -Medicare is the secondary payer for the 'working aged' who has a group health plan if the group has 20+ enrollees -For single employer with 20 employees with a group health plan, Medicare is the primary payer. -If individual retains coverage thru the group plan, the group contract is the primary unless person is retired & still covered under the group plan. In that case, Medicare is the primary. -If individual rejects the employer plan, Medicare is the primary payer Medicare as a secondary payer - Answer -In cases of Workers' Comp when it applies to an injury or illness - In cases where no-fault insurance or liability insurance is available as primary payer. Medicare & the VA - Answer Can choose to get treatment under either plan. Medicare usually will not pay benefits if services are rendered in a VA facility but will pay if outside of VA. There is NO coordination between Federal agencies. Expenses NOT paid by Medicare - Answer -Purely custodial care/ chronic care -Services that are not reasonable or medically necessary under Medicare standards -Services performed by relatives/ member of beneficiary's household -Services paid for by another gov't agency Medicare Part A covers - Answer -acute inpatient hospital care -inpatient skilled nursing care -medically necessary home health care & hospice services Medicare Deductible - Answer -Deductible must be met for ea. benefit period -Benefit period ends 60 days after discharge -Deductible is $1364 plus need to pay/ replace first 3 pts of blood per calendar year. Days 1 to 60 - Answer Non-Exhaustible Benefit -After deductible is met, Part A pays 100% of all approved hospital charges for first 60 days of confinement. From day 61 to 90th day of confinement - Answer Part A will pay 100% of approved charges less a copay of 25% of current deductible ($341) per day. -Also a non-exhaustible benefit 60 day Lifetime Hospital Reserve Benefit - Answer 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) - Answer 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 - Answer 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 - Answer -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) - Answer fixed payment scale/schedule based on your DRG (diagnosis related group) which is assigned at admission. DRG (Diagnosis Related Group Classification) - Answer -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) - Answer 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 - Answer Part A will pay benefits for a max of 190 days for inpatient psych care. Lifetime Maximum. What Medicare Part A covers - Answer -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 - Answer -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 - Answer 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 - Answer Skilled Intermediate Custodial