Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child.
What is Medicare Administrative Contractor?
an insurance company or other organization (e.g. a medicare administrative contractor) that processes health care claims for reimbursement of procedures and services. payers serve as medicare administrative contractors (MACs) by processing claims for
How does the federal government pay Medicare claims?
The federal government does not pay Medicare claims directly. Instead, it contracts with insurance organizations to process claims on its behalf. Insurance companies that process claims are called Medicare administrative contractors (MACs). Providers are assigned to a MAC based on the state in which they are physically located.
What is a Medicare Part A Fiscal Intermediary?
Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers.
What does the Medicare coordination of benefits contractor do?
The Medicare coordination of benefits contractor receives inquiries regarding Medicare as second payer and has information on a beneficiary's eligibility for benefits and the availability of other health insurance that is primary to Medicare.
What organization handles Medicare claims?
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP).
What is a Medicare carrier?
Carriers are private insurance companies acting under contract with the Health Care Financing Administration (HCFA) to processclaims by beneficiaries and providers for services or supplies covered under Medicare Part B. While most Stateshave jurisdiction for one State, a few carriers handle more than one State.
Under which of the following Medicare plans for primary care and specialists services is the patient required to pay a monthly premium quizlet?
* Part B is medical insurance for ambulatory care, including primary care and specialists for which patients are required to pay a monthly premium; Part B functions similar to a PPO in that patients can visit any specialist without a referral.
Which of the following agencies is responsible for Medicare quizlet?
An agency of the Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) administers the federal Medicare program.
What is a CMS contractor?
The Centers for Medicare & Medicaid Services (CMS) employs contractors to provide a wide range of services and makes data available to these contractors as needed to support their assigned work. A CMS Data Use Agreement (DUA) is used to create a traceable record of what data is being accessed by each CMS contractor.
What is the role of Medicare administrative contractors quizlet?
Insurance companies that process claims are called Medicare administrative contractors (MACs). Providers are assigned to a MAC based on the state in which they are physically located. Durable Medical Equipment (DME) MACs handle claims for durable medical equipment, supplies, and drugs billed by physicians.
Which program includes managed care and private fee-for-service plans that provide contracted care to Medicare patients?
Medicare Advantage (Medicare Part C), formerly called Medicare+Choice, includes managed care and private fee-for-service plans that provide contracted care to Medicare patients. Medicare Advantage is an alternative to the original Medicare plan reimbursed under Medicare Part A.
Does Managed Medicare follow Medicare guidelines?
Medicare Advantage Plans Must Follow CMS Guidelines In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover.
Which is the term for different types of health insurance payments made to providers for patient services?
Capitation payments are payments made to health care providers for providing services to patients. These payments are fixed and generally paid monthly (based on yearly contracts—i.e. capitation contracts).
Who runs many of the Medicare CCPS?
The Centers for Medicare and Medicaid Services is the federal agency that runs the Medicare program and works with states to manage the Medicaid program. It is an arm of the U.S. Department of Health and Human Services. You just studied 68 terms!
Which agencies can accredit hospitals for participation in Medicare and Medicaid programs?
Terms in this set (80)Accreditation. ... Admitting Privileges. ... Agency for Health Care Administration (AHCA) ... American Academy of Professional Coders (AAPC) ... American Health Information Management Association (AHIMA) ... American Osteopathic Association (AOA) ... Centers for Medicare and Medicaid Services (CMS)More items...
What is one of the responsibilities of health care regulatory agencies quizlet?
Oversee health policies and respective regulations; Responsible for disease monitoring and surveillance in their communities. -Set standards for and accredits, ambulartory care centers, hospitals, behavioral health and long-term care facilities.
What is the difference between HCPCS and AMA?
HCPCS is composed of Level I and Level II codes; the differences between the two levels are: a. Level I codes are maintained by the AMA, whereas Level II codes are developed by hospitals as part of their charge master. b. Insurance companies need Level II codes to process claims, insurers do not process Level I codes.
What is the risk of a payer?
For the payer, the risk is that claims for payment and administrative costs will exceed the premiums received. The payer may raise premiums to compensate; however, in so doing, the payer may lose subscribers. Overall, the financial risks and rewards in the health care industry are a delicate balancing act.
What are the different types of reimbursement?
List and describe the four types of reimbursements: 1. Fee for service reimburses the provider at a rate set by the provider, based on the services rendered. 2. Discounted fee for service reimburses the provider at a rate set by the provider, less a negotiated discount, based on the services rendered. 3.
What's a MAC and what do they do?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
DME MACs
The DME MACs process Medicare Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) claims for a defined geographic area or "jurisdiction", servicing suppliers of DMEPOS. Learn more about DME MACs at Who are the MACs.
Relationships between MACs and Functional Contractors
MACs work with multiple functional contractors to administer the full FFS operational environment. Learn more about the relationships between the MACs and the functional contractors by viewing the diagram of MACs: The Hub of the Medicare FFS Program (PDF) and reading about what the functional contractors do at Functional Contractors Overview (PDF).
What is Medicare insurance?
Medicare. A federal program of health insurance for persons 65 years of age and older. For individuals who already have health insurance, the intent of the affordable care act of 2010 is to provide more stability and security by: -ending discrimination against people with pre-existing conditions.
What is private health insurance?
Private health insurance usually consists of an indemnity plan, which covers individuals for certain health care expenses. The insurance company reimburses the patient or the provider, depending on the contract language. individuals pay annual premiums (with predetermined rates) employer based group health insurance.
What is a third party payer?
a third party payer is. an insurance company or other organization (e.g. a medicare administrative contractor) that processes health care claims for reimbursement of procedures and services. payers serve as medicare administrative contractors (MACs) by processing claims for.
What is the NPI code?
National Provider Identifier (NPI) Unique 10-digit code for providers required by HIPAA. (doctors, nursing homes, and other health care providers, for filing electronic claims with public and private insurance programs. providers apply for NPI once and keep it if they relocate or change specialties.
What percentage of health insurance premiums does an employer pay?
the employer typically pays 80 percent of insurance premiums, and the employee pays the remaining 20 percent. the employer generally contracts with a commercial health insurance plan (aetna) premium. an amount to be paid for an insurance policy. deductible.
What is Blue Cross insurance?
a health insurance organization that covers the cost of hospital care and physician services. blue cross initially just covered. hospital care. blue shield initially just covered. physicians services. commercial payers. include private health insurance and employer based group health insurance.
What are non-institutional providers?
noninstitutional providers (e.g., physician offices, independent labs, ambulance companies that are not associated with a hospital, ambulatory surgery centers, and independent diagnostic testing facilities) and suppliers (for durable medical equipment, prosthetics, orthotics, and supplies dealers.
What information must a Medicare plan disclose?
Manage care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval. encourage them to reduce or limit patient services.
What is an HMO?
The Health Maintenance Organization (HMO) Assistance Act of 1973 authorized grants and loans to develop HMOs under private sponsorship. It defines a federally qualified HMO as being certified to provide health care services to____________ enrolles. Click card to see definition 👆. Tap card to see definition 👆.
What Is a MAC?
Think of a MAC as a middleperson between you, your doctor and the Centers for Medicare & Medicaid Services (CMS). Each geographic region (also known as jurisdiction) has a specific MAC that handles the payment side of the Medicare fee-for-service program. MACs are also charged with conducting audits and educating providers.
How Many Macs Exist?
Currently, there are 12 Medicare Part A and B MACs that assist with Original Medicare (Medicare Parts A and B). Four of these MACs also process home health and hospice claims in addition to their typical Medicare Part A and Part B claims. There are also four durable medical equipment (DME) MACs.
Why Are MACs Important?
MACs are important because they ensure your doctor gets paid correctly. They also create what’s called local coverage determinations (LCD) based on whether an item or service is considered reasonable and necessary. LCDs exist in the absence of a national coverage policy, and they may vary from jurisdiction to jurisdiction.
When Would I Need to Find a Specific LCD?
You might need to find an LCD if you’re filing an LCD challenge. You can do this if you have Medicare Part A, Medicare Part B (or both), and you need the item or service that’s not covered by the LCD. However, you need to file your request within six months of the date of the treating doctor’s written statement that you need the item or service.
What should an MA organization do before contracting with CMS?
Before an MA organization contracts with an entity to perform functions that are otherwise the responsibility of the MA organization under its contract with CMS, the MA organization should develop, implement, and maintain policies and procedures for assessing contracting provider groups' administrative and fiscal capacity to manage financial risk prior to delegating MA-related risk to these groups. Suggested policies and procedures include:
Who audits MA contracts?
DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the MA organization or relating to the MA organization's MA contract. DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the related entity, contractor, subcontractor, or its transferee that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under the contract, or as the Secretary may deem necessary to enforce the MA contract.
How long do you have to give CMS notice?
The organization must give CMS notice at least 90 days before the intended date of termination which specifies the reasons the MA organization is requesting contract termination.
What is the MA administrative contracting requirement?
The MA administrative contracting requirements apply both to first tier contracts and to downstream contracts in the manner specified for provider contracts, as described above. At the same time, the responsibility of the MA organization is to assure that its contractor and any downstream contractors have the information necessary to know how to comply with the requirements under the MA program.
How long does a MA contracting prohibition last?
An MA organization will be subject to a 2-year contracting prohibition when the organization leaves the MA program entirely by non-renewing all of its MA contracts. As long as an MA organization continues to offer at least one MA plan, the prohibition will not apply. If an MA organization that non-renews all of its MA contracts proposes to return to Medicare contracting within the 2-year time period, the organization must provide a written request to CMS asking for an exemption to the prohibition based on special circumstances. The MA organization will automatically be permitted to re-enter the program as of the beginning of the next calendar year if, during the 6-month period beginning on the date the organization notified CMS of the intention to non-renew all of its MA contracts, there was a change in the statute or regulations that had the effect of increasing MA payments in the payment area or areas at issue. The MA organization will also be permitted to re-enter the program if "circumstances. . .warrant special consideration." CMS will evaluate proposed special circumstance requests on a case-by-case basis. However, there are certain special circumstances under which CMS generally will grant an exemption to the 2-year contracting prohibition to allow the MA organization to offer an MA or MA-PD plan as of the beginning of the next calendar year. These circumstances are:
Can a MA organization terminate a contract?
There are circumstances under which an MA organization may agree to a termination by mutual consent. Further, CMS may decide that it is in the best interests of tax payers, Medicare beneficiaries and the Medicare program to agree to let an MA organization terminate its contract midyear.
Does CMS enter into a contract with an entity?
Unless an organization has a minimum enrollment waiver as explained below, CMS does not enter into a contract with an entity unless it meets the following minimum enrollment requirements: