B&C Chapter 14: Medicare Flashcards
(41 cards)
advance beneficiary notice of noncoverage (ABN)
document that acknowledges patient responsibility for payment if Medicare denies the claim.
benefit period
begins with the first day of hospitalization and ends when the Medicare patient has been out of the hospital for 60 consecutive days.
conditional primary payer status
Medicare claim process that includes the following circumstances: a plan that is normally considered to be primary to Medicare issues a denial payment that is under appeal; a patient who is physically or mentally impaired failed to file a claim to the primary payer; a workers’ compensation claim has been denied and the case is slowly moving through the appeal process; or there is no response from a liability payer within 120 days of filing the claim.
coordinated care plan
also called managed care plan; includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs), through which a Medicare beneficiary may choose to receive health care coverage and services.
demonstration/pilot program
special projects that tests improvements in Medicare coverage, payment, and quality of care.
diagnostic cost group hierarchical condition category (DCG/HCC) risk adjustment model
CMS model implemented for Medicare risk-adjustment purposes and results in more accurate predictions of medical costs for Medicare Advantage enrollees; its purpose is to promote fair payments to managed care organizations that reward efficiency and encourage excellent care for the chronically ill.
employer-sponsored group health plan (EGHP)
allows a large employer to assume the financial risk for providing health care benefits to employees; employer does not pay a fixed premium to a health insurance payer, but established a trust fund (of employer and employee contributions) out of which claims are paid.
general enrollment period (GEP)
enrollment period for Medicare Part B held January 1 through March 31 of each year.
hospice
autonomous, centrally administered program of coordinated inpatient and outpatient palliative services for terminally ill patients and their families.
initial enrollment period (IEP)
seven-month period that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B.
lifetime reserve days
may be used only once during a patient’s lifetime and are usually reserved for use during the patient’s final, terminal hospital stay.
mass immunizer
traditional Medicare-enrolled provider/supplier or a non-traditional provider that offers influenza virus and/or pneumococcal vaccinations to a large number of individuals.
medical necessity denial
denial of otherwise covered services that were found to be not “reasonable and necessary.”
Medicare Advantage (Medicare Part C)
includes managed care plans and private fee-for-service plans, which provide care under contract to Medicare and may include such benefits as coordination of care, reductions in out-of-pocket expenses, and prescription drugs. Medicare enrollees have the option of enrolling in one of several plans; formerly called Medicare+Choice.
Medicare Cost Plan
type of HMO similar to a Medicare Advantage Plan; if an individual receives care from a non-network provider, the original Medicare plan covers the services.
Medicare-Medicaid crossover
combination of Medicare and Medicaid programs; available to Medicare-eligible persons with incomes below the federal poverty level.
Medicare Part A
reimburses institutional providers for inpatient, hospice, and some home health services.
Medicare Part B
reimburses noninstitutional health care providers for outpatient services.
Medicare Part D coverage gap
the difference between the initial coverage limit and the catastrophic coverage threshold, as described in the Medicare Part D prescription drug program administered; a Medicare beneficiary who surpasses the prescription drug coverage limit is financially responsible for the entire cost of prescription drugs until expenses reach the catastrophic coverage threshold; also called the Medicare Part D “donut hole.”
Medicare Part D “donut hole”
the MMA private prescription drug plans (PDPs) and the Medicare Advantage prescription drug plans are collectively referred to as Medicare Part D; MMA requires coordination of Medicare Part D with State Pharmaceutical Assistance Programs (SPAPs), Medicaid plans, group health plans, Federal Employee Health Benefit Plans, and military plans such as TRICARE; Medicare Part D enrollment is voluntary, and beneficiaries must apply for the benefit.
Medicare Part D sponsor
organization that has one or more contract(s) with CMS to provide Part D benefits to Medicare beneficiaries.
Medicare Prescription Drug Plans
prescription drug coverage added to the original Medicare plan, some Medicare Cost Plans, some Medicare private fee-for-service plans, and Medicare Medical Savings Account Plans; Medicare beneficiaries present a Medicare prescription drug discount card to pharmacies.
Medicare private contract
agreement between Medicare beneficiary and physician or other practitioner who has “opted out” of Medicare for two years for all covered items and services furnished to Medicare beneficiaries; physician/practitioner will not bill for any service or supplies provided to any Medicare beneficiary for at least two years.
Medicare Secondary Payer (MSP)
situations in which the Medicare program does not have primary responsibility for paying a beneficiary’s medical expenses.
