Which of the following is not covered by Medicare quizlet?
Medicare Part A covers 80% of the cost of durable medical equipment such as wheelchairs and hospital beds. The following are specifically excluded: private duty nursing, non-medical services, intermediate care, custodial care, and the first three pints of blood.
Which of the following is excluded under Medicare?
Non-medical services, including a private hospital room, hospital television and telephone, canceled or missed appointments, and copies of x-rays. Most non-emergency transportation, including ambulette services. Certain preventive services, including routine foot care.
Which is the maximum reimbursement a nonparticipating physician who does not accept Medicare assignment may receive from Medicare?
If a physician is a nonparticipating physician who does not accept assignment, he can collect a maximum of 15% (the limiting charge) over the non-PAR Medicare Fee Schedule amount.
Can Medicare deny treatment?
Absolutely. Sometimes Medicare will decide that a particular treatment or service is not covered and will deny a beneficiary's claim.
What are Medicare exclusions?
Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, ...
Which of the following is not covered under Medicare Part B?
But there are still some services that Part B does not pay for. If you're enrolled in the original Medicare program, these gaps in coverage include: Routine services for vision, hearing and dental care — for example, checkups, eyeglasses, hearing aids, dental extractions and dentures.
Which is the maximum reimbursement a nonparticipating physician who does not accept Medicare assignment may receive from Medicare quizlet?
It is mandatory on the CMS-1500 and UB-04 claim forms. $66.50. If a physician is a nonparticipating physician who does not accept assignment, he may collect a maximum of 15% (the limiting charge) over the non-PAR Medicare fee schedule amount. Medicare fee schedule amount and the total charge amount.
Which is the maximum reimbursement a nonparticipating physician may receive from Medicare?
The maximum amount that a nonparticipating physician, other practitioner or supplier is permitted to charge for a Medicare beneficiary for unassigned services paid under the physician fee schedule is 115% of the Medicare allowed charge.Feb 1, 2018
What happens when Medicare denies a claim?
An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies: A request for a health care service, supply, item, or drug you think Medicare should cover.
Which of the following is covered by Medicare Part A?
Medicare Part A hospital insurance covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care.
What are 3 rights everyone on Medicare has?
— Call your plan if you have a Medicare Advantage Plan, other Medicare health plan, or a Medicare Prescription Drug Plan. Have access to doctors, specialists, and hospitals. can understand, and participate in treatment decisions. You have the right to participate fully in all your health care decisions.
Which of the following is Medicare Part B also known as?
Medicare Part B (also known as medical insurance) is an insurance plan that covers medical services related to outpatient and doctor care.
What is a kickback in healthcare?
Kickbacks are anything of value presented to a practitioner or supplier that may induce that entity to refer health services back to the source of remuneration.
What is the Stark II law?
The Stark II law (introduced by Rep. Pete Stark, D-CA) designates ten categories of Medicare and Medicaid health services for which self-referral is prohibited.
Does Medicare cover hearing aids?
While Medicare does not cover hearing aids, a Medicaid program that defines hearing aids as durable medical equipment or a prosthetic device (Stark designated health services) could link the audiology services to the self-referral law. This issue is subject to further legal interpretation.
Does Stark law apply to Medicare?
The Stark law prohibits a physician with a financial relationship in an entity from making a referral for designated health services covered by Medicare and Medicaid to that entity even if the services are billed to an individual or other third party payer. The anti-kickback regulations apply only to services reimbursed by Medicare or Medicaid.
What Does CMS Consider a Sales Event or Appointment?
An activity will be considered a sales event or appointment if it is designed to persuade potential enrollees to choose a specific plan (or set of plans), according to CMS. The inclusion of plan-specific information, sales techniques, and the collection of applications differentiate these events from educational events.
What Brokers Should Do Before an Event or Appointment
Before brokers conduct sales events or appointments, they must submit all sales scripts and presentations to the insurance company they represent. The insurance company is then responsible for submitting those sales and marketing items to CMS for approval.
Brokers Are Allowed to Do These Things During an Event or Appointment
Brokers are allowed to do the following during a sales event or appointment.
Brokers Must Avoid These Activities During an Event or Appointment
The following activities are prohibited during sales events and appointments.
Where to Find More Medicare Marketing Guidelines
Excelsior is taking the time to break down each Medicare Marketing Guideline that brokers need to know. Just visit our online resource center. And if you’re more interested in learning what else Excelsior can do for you, such as teaching you how to double or triple your revenue, contact us today.
What is Medicare marketing guidelines?
The Medicare Marketing Guidelines (MMG) implement the Centers for Medicare & Medicaid Services’ (CMS) marketing requirements and related provisions of the Medicare Advantage (MA, MA-PD ) (also referred to as Plan), Medicare Prescription Drug Plan (PDP) (also referred to as Part D Sponsor), and except where otherwise specified, Section 1876 cost plans (also referred to as Plan) rules, (i.e., Title 42 of the Code of Federal Regulations, Parts 422, 423, and 417). These requirements also apply to Medicare-Medicaid Plans (MMPs), except as modified or clarified in state-specific marketing guidance for each state’s demonstration. State-specific guidance is considered an addendum to the MMG. State-specific marketing guidance for MMPs will be posted to http://www.cms.gov/Medicare-
What is an educational event for Medicare?
Educational events are designed to inform Medicare beneficiaries about Medicare Advantage, Prescription Drug or other Medicare programs and do not include marketing (i.e., the event sponsor does not steer, or attempt to steer, potential enrollees toward a specific plan or limited number of plans).
What is a non-benefit/non-health service provider?
Third parties that provide non-benefit/non-health services (“Non-benefit/non-health service providing third party entities”) are organizations or individuals that supply non-benefit related information to Medicare beneficiaries or a Plan’s/Part D Sponsor’s membership, which is paid for by the Plan/Part D Sponsor or the non-benefit/non-health service-providing third-party entity.
What is Ad hoc enrollment?
Ad hoc enrollee communication materials are informational materials that are targeted to current enrollees, are customized or limited to a subset of enrollees, apply to a specific situation or cover enrollee-specific claims processing or other operational issues, and do not include information about the plan’s benefit structure. In addition, these communication materials are not tied to regularly occurring events such as aging into Medicare, the Annual Enrollment Period, or a new contract year. These materials are not considered marketing materials. Examples include, but are not limited to, the following:
What is co-branding in Medicare?
Co-branding is defined as a relationship between two or more separate legal entities, one of which is an organization that sponsors a Medicare plan. Co-branding is when a Plan/Part D Sponsor displays the name(s) or brand(s) of the co-branding entity or entities on its marketing materials to signify a business arrangement. Co-branding arrangements allow a Plan/Part D Sponsor and its co-branding partner(s) to promote enrollment in the plan. Co-branding relationships are entered into independent of the contract that the Plan/Part D Sponsor has with CMS.
What is a script in Medicare?
Informational scripts are designed to respond to beneficiary questions and requests and provide objective information about a plan or the Medicare program. Sales and enrollment scripts are intended to steer a beneficiary towards a plan or limited number of plans, or to enroll a beneficiary into a plan.
What is a third party marketing organization?
Third-party marketing organizations are entities such as a Field Marketing Organization (FMO), General Agent (GA), or similar type of organization that has been retained to sell or promote a Plan’s/Part D Sponsor’s Medicare products on the Plan’s/Part D Sponsor’s behalf either directly or through sales agents or a combination of both.
