Medicare - Jan. 21 & 23

Question 1

When were Medicare and Medicaid passed? (Q)

Answer 1

1965

Question 2

What department of the federal government administers Medicare? (Q)

Answer 2

Medicare is administered by an agency within the Department of Health and Human Services (HHS) called the Centers for Medicare and Medicaid Services, or CMS.

Question 3

Who is automatically eligible for Medicare? (Q)

Answer 3

United States citizens and lawful residents are automatically eligible for Medicare if they’re over age 65 and have paid Social Security taxes for at least 40 calendar quarters, or 10 years. 42 U.S.C § 426.

Question 4

Does the automatic Medicare eligibility apply if the person is still working or has other income? (Q)

Answer 4

Yes.

Question 5

Who else is eligible for Medicare? (Q)

Answer 5

Some spouses and former spouses of eligible individuals are also eligible even if the spouse never worked, and some federal retirees are eligible regardless of age.

Question 6

How may disabled individuals be eligible for Medicare? (Q)

Answer 6

Disabled individuals may be eligible for Medicare if they qualify for Social Security or federal railroad retirement benefits; have end-stage renal disease; or have ALS, also known as Lou Gehrig’s disease.

Question 7

How are Medicare benefits broken down? (Q)

Answer 7

Medicare benefits are broken into Parts A, B, C, and D.

Question 8

What does Part A of Medicare cover? (Q)

Answer 8

Part A covers inpatient care, like hospital stays, skilled-nursing-facility stays, hospice care, and some home-health services.

Question 9

What does Part B of Medicare Cover? (Q)

Answer 9

Part B covers outpatient services, like outpatient hospital visits, doctor’s office visits, durable medical equipment, and ambulance services.

Question 10

What don’t Parts A and B of Medicare cover? (Q)

Answer 10

Parts A and B don’t cover dental or vision services.

Question 11

What is Part C of Medicare? (Q)

Answer 11

Part C is a managed-care alternative to Parts A and B that covers the same care plus sometimes dental and vision services.

Question 12

What does Part D of Medicare cover? (Q)

Answer 12

Part D covers prescription drugs.

Question 13

Which parts of Medicare are referred together as “Traditional Medicare”? (Q)

Answer 13

Traditional Medicare refers to Parts A and B.

Question 14

What do Parts A and B of Medicare have in common? (Q)

Answer 14

Both parts are administered by the federal government and allow beneficiaries to choose any provider that accepts Medicare. Both parts may require beneficiaries to pay deductibles and to provide coinsurance for some services.

Question 15

What is a deductible? (Q)

Answer 15

A deductible is an amount the beneficiary must pay before insurance will pay for services.

Question 16

What is coinsurance? (Q)

Answer 16

Coinsurance is a percentage of a bill that the beneficiary pays even after meeting a deductible.

Question 17

Is there a cap on the maximum amount that a beneficiary may owe for deductibles and coinsurance under Parts A and B? (Q)

Answer 17

No.

Question 18

What is one significant difference between Parts A and B of Medicare? (Q)

Answer 18

One significant difference between these two parts is their premiums.

Question 19

What is Part A’s premium? (Q)

Answer 19

For Part A, coverage is free for beneficiaries over 65 who’ve paid Social Security taxes for 40 quarters (no premium) and is available for a small premium to others.

Question 20

What is part B’s premium? (Q)

Answer 20

For Part B, everyone must pay a premium. However, people with low income may qualify to have Medicaid cover their Part B premium.

Question 21

What is Part C also known as? (Q)

Answer 21

Part C is known as Medicare Advantage.

Question 22

How may a beneficiary of Medicare choose Part C? (Q)

Answer 22

A beneficiary may select Part C as an alternative to Parts A and B.

Question 23

What happens when a beneficiary chooses Part C? (Q)

Answer 23

The beneficiary then chooses a private managed-care plan from several options, many of which are administered by health-maintenance organizations, or HMOs.

Question 24

What are the downsides of HMOs? (Q)

Answer 24

HMOs frequently offer a limited provider network and require referrals from a primary-care manager to see specialists.

Question 25

What do beneficiaries who choose Part C have to pay? (Q)

Answer 25

Part C plans may require beneficiaries to pay premiums, deductibles, and copays.

Question 26

What are copays? (Q)

Answer 26

Copays are flat-fee amounts that a beneficiary contributes to a medical service.

Question 27

What is the difference between copays in Part C as opposed to Parts A and B? (Q)

Answer 27

Unlike Parts A and B, Part C caps the maximum amount that a beneficiary is required to spend out of pocket.

Question 28

What entity funds Medicare's Part D? (Q)

Answer 28

The federal government funds Part D’s prescription-drug benefits.

Question 29

What entity administers Part D's prescription-drug benefits? (Q)

Answer 29

Private plans administer those benefits.

Question 30

How can a beneficiary have Part D's coverage? (Q)

Answer 30

A beneficiary may have Part D coverage included with some Part C plans or purchase it as an add-on to any Medicare coverage.

Question 31

How may Medicare beneficiaries supplement their plans? (Q)

Answer 31

Medicare beneficiaries may also purchase supplemental private insurance, such as dental or vision insurance or a product called Medigap, which helps cover the unlimited out-of-pocket expenses under Parts A and B.

Question 32

What reimbursement system do Parts A and B use? (Q)

Answer 32

Currently, Parts A and B use prospective-payment systems.

Question 33

What is a prospective-payment system? (Q)

Answer 33

A prospective-payment system uses a preset amount for each medical service. If a provider accepts a Medicare patient, the provider agrees to accept reimbursement at that preset amount.

Question 34

What are Medicare's Part A preset reimbursement amounts for hospitals and other inpatient providers based on? (Q)

Answer 34

Medicare Part A’s preset reimbursement amounts for hospitals and other inpatient providers are based on which Diagnoses-Related Group, or DRG, applies to a patient’s particular diagnosis.

Question 35

How may a preset amount for a diagnosis be adjusted? (Q)

Answer 35

The preset amount for a diagnosis may be adjusted to reflect a particular facility’s individual factors, with upward adjustments for hospitals that provide public services, like teaching hospitals or hospitals in underserved communities.

Question 36

What did the Affordable Care Act (ACA) do to help Medicare benefits regarding quality of care? (Q)

Answer 36

The ACA created a value-based purchasing program tying Part A payments to quality in some ways. For instance, the act imposes financial penalties on hospitals that have high readmission rates for Medicare beneficiaries.

Question 37

What are Part B's preset reimbursement amounts for doctors based on? (Q)

Answer 37

Part B’s preset reimbursement amounts for doctors are based on a particular medical service’s current procedural terminology, or CPT, code.

Question 38

How are CPT's similar to DRG's? (Q)

Answer 38

Like a DRG’s preset amounts, a CPT code’s preset amount may be adjusted for specific providers to account for a provider’s individual factors.

Question 39

How are Part C's managed-care plans reimbursed? (Q)

Answer 39

Part C’s managed-care plans are reimbursed a monthly amount for providing coverage to beneficiaries.

Question 40

How is the monthly amount for Part C's managed-care plans reimbursement set? (Q)

Answer 40

The monthly amount is set using a bidding system, with different financial risks and benefits for bids that are above and below a benchmark amount set by CMS.

Question 41

How did the ACA account for care quality with respect to Part C? (Q)

Answer 41

To account for care quality, the Affordable Care Act implemented the Star Rating Program for Part C reimbursements. Among other things, if a health plan provides quality care as defined by the program’s metrics, the plan receives a bonus payment.

Question 42

What is the Emergency Medical Treatment and Active Labor Act (EMTALA)? (Deliganis)

Answer 42

EMTALA covers medical facilities that accept medicare reimbursement and have emergency departments, must screen and stabilize emergency patients, need not provide full course of treatment (but no delays), need not provide free treatment (but can’t refuse based on payment).