Chapter 9 Medicare Challenges

In order for a service/procedure/supply to be covered under medicare, it must be considered?

Medically Necessary

What is Medically Necessary?

Reasonable and necessary for diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part

What is Medicare?

Comprehensive federal insurance program

When was Medicare established?and Why?

established in 1966 to provide 65 and older with financial assistance for medical expenses

Who administers Medicare?

centers of medicare and medicaid services (CMS) administer Medicare

Beneficiaries are required to pay part of cost in the from of what?

1) subject to change every year 2) premiums3) deductibles4) coinsurance

What does Late enrollment mean?


What are the four parts of Medicare?

Part A: hospital insurancePart B: Medical (physicians care) insurancePart C: Medical AdvantagePart D: Prescription drug program

What is Part A?

hospital insurance

What is Part B?

medical (physician care)insurance

What is Part C?

Medical Advantage

What is Part D?

Prescription drug program

Medical insurances financed by a combination of federal government funds and beneficiary premiums, which help play for what?

1) Medically Necessary physicians services 2) Outpatient services

Medicare Part A helps pay for medical necessary services of the following types of healthcare:

1) Inpatient hospital care2) Inpatient care in a skilled nursing facility (SNF)3) Home Healthcare4)Hospice care and blood

In Part B are all beneficiaries pay for Part B coverage ?


The part B monthly premiums changes every ?


What is deducted from the beneficiary's month social security benefits check?


What does Part B determine?

payments of Part B covered items and services

In Medicare Part C Medicare Advantages (MA) option plans formally called what?

Medicare+ Choice

Offer prescription drug coverage to everyone eligible for Medicare started when?

started in 2003, becomes effect 01/01/2006

What should patients sign if Medicare will not pay for a test or procedure ?

Patient should sign ABN (Advance Beneficiary Notice)

In Advance Beneficiary Notice(ABN) procedures/service(s) requested must be eligible for ?

Medicare Coverage

Medicare pays ______ of the allowable charges after deductible is met


Fees that Medicare permits for are?

1) particular procedures2) service3) supplies