Medical Insurance Ch. 9,10,11 review: Overview

Medicare benefits are available to individuals under
One of six beneficiary categories
Disabled adults may be eligible for
Medicare benefits
Hospital benefits are provided by
Medicare Part A
Outpatient hospital benefits are provided by
Medicare part B
Hospice benefits are provided by
Medicare part A
Home Healthcare is provided by
Medicare part A
Skilled Nursing Care is provided by
Medicare part A
The coinsurance for Medicare Part B is
20 percenf
Medicare Part B is also called
Supplemental Medical Insurance
Durable Medical Equipment is covered by
Medicare Part B
Medicare Part A is administered by
The prescription drug plan is offered by
Medicare Part D
Medicare Advantage is part of
Medicare Part C
Each Medicare enrollee receives a Medicare card issued by the
Social Security Administration
IPPE is the abbreviation for
Initial preventive physical examination
AWV is the abbreviation for
Annual wellness visit
In cases when immunizations are covered, they are covered by
Medicare Part B
Medicare does not provide benefits for
Cosmetic surgery
Physicians who participate in the Medicare Program must accept
Assignment and file claims for beneficiaries
MACs are paid to process claims for
Government medical insurance programs
ABN is the abbreviation for
Advance beneficiary notification
NCD stands for
National coverage determination
LCD is the abbreviation for
Local coverage determination
LCDs are coverage decisions that help providers
Determine medical necessity under Medicare
The Medicare limiting charge is the
Highest fee that can be charged for a procedure by nonparticipating provider
The Medicare program employs MACs to pay the claims
Submitted by providers
Medicare beneficiaries can select from a traditional
Fee for service or managed care
Medicare beneficiaries receive a MSN (Medical summary notice), which is an
Explanation of Medicare benefits
MSA is the abbreviation for
Medicare medical savings account
MAO is the abbreviation for
Medicare advantage organization
Urgently needed care is defined in the Medicare program as
Unexpected illness or injury that requires immediate treatment
CCP is the abbreviation for
Medicare coordinated care plans
A Medigap insurance plan is an insurance offered by
Private insurance carrier
Supplemental insurance plans for Medicare beneficiaries provide
Additional coverage for an individual receiving benefits under Medicare Part B
CCI is the abbreviation for
Medicare’s correct coding initiative
OIG is the abbreviation for
Office of the inspector general
Roster billing applies to
Medicare Part B
A duplicate claim is defined as those sent to one or more Medicare contractors from
the same provider for the same beneficiary, the same service and the same date of service
Most Medicare claims are HIPAA 837P transactions and are transmitted
Both patients and providers have the right to
Appeal denied Medicare claims
Anyone over age 65 who receives Social Security benefits is automatically enrolled in
Medicare Part A and eligible to enroll in Part B
People who are over age 65 but who are not eligible for free Part A coverage may enroll by
Paying a premium
Medicare Part A is also called
Hospital Insurance
Medicare Part D provides voluntary Medicare
Prescription drug plans
Medicare Part B is also called
Supplementary medical insurance
115 percent of the fee on the Medicare NonPAR fee schedule equals the
Limiting charge
Patients receive a Medicare Summary Notice (MSN) that details the
Services they were provided over a 30 day period, the amounts charged, and the amounts they may be billed
FMAP is the abbreviation for
Federal Medicaid assistance percentage
Medicaid beneficiaries must meet both
Minimum federal requirements as well as any additional state requirements
A person eligible for Medicaid in a given state is not necessarily eligible in
All states
Categorically needy people in the Medicaid program usually don’t have
High incomes
CHIP is the abbreviation for
Children’s health insurance program
TANF is the abbreviation for
Temporary assistance for needy families
Individuals receiving financial assistance under TANF due to low incomes and few resources must be covered by
State Medicaid programs
SSI is the abbreviation for
Supplemental security income
Children under 6 years old who meet TANF requirements or whose family income is below 133 percent of the poverty level must be offered state
Medicaid benefits
The EPSDT (early and periodic screening, diagnosis, and treatment) program of Medicaid covers
Children under age 21
A burial plot is not considered an
The medical insurance specialist should check patient’s Medicaid eligibility each time
An appointment is made
EMEVS stands dor
Electronic Medicaid eligibility verification system
Medicaid is referred to as the
Payer of last resort
Under the payer of last resort regulation, Medicaid pays last on a claim when a patient has
Other effective insurance coverage
Dual eligibility refers to
Medicaid and Medicare
Medicaid claims are usually submitted using the
HIPAA 837P claim
The TANF program under Medicaid offers financial assistance for people with
Low incomes and few resources
The federal government sends Medicaid funding to states under the
FMAP profram
Medicaid is jointly funded by federal and
State governments
Medicaid provides preventive services to children under age 21 under the
ESPDT program
The CHIP program under Medicaid offers health insurance coverage for
Uninsured children
Federal guidelines mandate coverage for individuals referred to as
Categorically needy
All categories of peoples’ assets except ownership of a home must be considered in determining
Medicaid eligibility
People who receive income from employment may qualify for Medicaid depending on the
In restricted status, the patient is required to see a
Specific physician and/or use a specific pharmacy
Under a state’s Medicaid program, cosmetic procedures may
Not be covered
Many states have moved beneficiaries to
Managed care plans
A physician who wishes to provide services to Medicaid recipients must
Sign a contract with the department of health and human services (HHS)
Claims billed to Medicare which are automatically sent to Medicaid are caleld
Crossover claims
Physicians who contract with Medicaid to provide services may not bill for services that are
Not medically necessary, submit claims for individual procedures that are part of a global procedure, or bill for services not provided
The uniformed services member in a family qualified for TRICARE is called the
TRICARE is the department of defense’s health insurance plan for
Military personnel and their families
Info about TRICARE patient eligibility is stored in the
Defense enrollment eligibility reporting system (DEERS)
TRICARE, which includes managed care options, replaced the program known as
TRICARE brings the resources of military hospitals together with a network of civilian facilities and providers to offer
Increased access to healthcare services
Providers may not contact DEERS directly because the info is protected by the
Privacy Acy
All military treatment facilities, including hospitals and clinics, are part of the
TRICARE system
The expiration date on an individual’s military ID card should be checked to confirm that
Coverage is still valid
TRICARE pays only for services rendered by
Authorized providers
A provider who chooses not to participate may not charge more than
115 percent of the allowable charge
Coat share is a TRICARE term for
TRICARE’s fiscal year is from
October 1 through September 30
Providers who choose not to join the TRICARE network may still provide care to managed care patients, but TRICARE will not pay for the
Services, the patient is 100 percent responsible for the charges
The maximum amount TRICARE will pay for a procedure is known as the
TRICARE Maximum Allowable Charge (TMAC)
The TRICARE program that offers fee for service coverage is
TRICARE Standard
The TRICARE program that offers an HMO- like plan requiring no annual deductible is
The TRICARE program that offers an alternative managed care plan to TRICARE Prime with no annual enrollment fee is
The TRICARE program that offers benefits to active duty reservists is
TRICARE Reserve Select
After enrolling in TRICARE Prime, individuals are assigned a Primary Care Manager (PCM) who
Coordinates and manages their medical care
Retirees and their families, former spouses, and families of deceased personnel pay a
25 percent cost share for outpatient services
A catchment area is a
Geographic area served by a hospital, clinic, or dental clinic
Under TRICARE Prime, there is no deductible, and no
Payment is required for outpatient treatment at a military facility
The TRICARE program that offers benefits to Medicare-eligible military retirees and family members is
TRICARE for Life
Medi-medi beneficiaries is an individual who is eligible for both
Medicare and Medicaid
TRICARE for Life offers the opportunity to receive healthcare at a military treatment facility to individuals age
65 and over who are eligible for both Medicare and TRICARE
Benefits are similar to those of a Medicare HMO, with an emphasis on preventive and wellness services; prescription drug benefits are also included in
TRICARE for Life
All enrollees in TRICARE for Life must be enrolled in
Medicare parts A and B and pay Part B premiums
Treatment at a civilian network facility requires a copay for
TRICARE for Life beneficiaries
Best practice for filing paper claims is to check with each payer for
Specific information required on the form