Medicare
What are the 3 Medicare Entitlement Reasons?
Age, Disability, ESRD
What is In-Network and Out-of-Network?
INN- Provider is in the plans network. Patient may have little to no out-of-pocket cost.
OON- Provider is out of the plans network. Patient may have higher out-of-pocket cost.
What is a Medicare Advantage Plan?
Federal Health Insurance. A person assigned their Medicare benefits to a commercial plan, person must pay premiums for both Medicare Part B and commercial plan to remain active.
What is Full Scope Medicaid?
Provides health coverage to people with low-income and asset levels who meet certain eligibility requirements.
What is Travel Insurance?
Commercial insurance purchased for person traveling internationally. DaVita does not accept travel insurance if dialysis is not a covered service.
What are the Medicare qualifying requirements?
Work Quarters (40 quarters for 65 or older, reduced if under the age of 65)
Citizenship (U.S Citizen or Legal Resident)
What does HMO, EPO, PPO and POS stand for?
HMO- Health Maintenance Organization
EPO- Exclusive Provider Organization
PPO- Preferred Provider Organization
POS- Point of Service
What is a Renal Program?
A state funded program for ESRD services only. This is available in 14 states and services covered may vary. Person may qualify for Renal program even if they exceed the income guidelines of straight Medicaid. Payor of last resort.
What is QMB Medicaid? What is SLMB Medicaid?
QMB- Qualified Medicare Beneficiary. Medicaid agency pays Medicare Part A/B premiums, also covers any deductible/co-insurance not covered by Medicare.
SLMB- Specified Low Income Medicare Beneficiary. Medicaid agency pays Medicare Part A/B premiums, DOES NOT cover any deductible/co-insurance assigned by Medicare.
When would DaVita bill a Workers Comp claim?
If patient's ESRD diagnosis was a direct result of injury at work then DVA would bill Workers Comp and not patient commercial/government insurance.
What are the 4 Parts of Medicare?
Part A- Hospital Insurance
Part B- Medical Insurance
Part C- Medicare Advantage
Part D- Prescription Drug Coverage
What is an EGHP/COBRA Plan?
Employer Insurance- Both thru active and not actively working employment. Can be thru self or spouse/parent. Self-funded plans are federally governed and fully funded and state governed.
What is an I.H.S Plan?
Indian Health Services. Federal government program that delivers health care to American Indians and Alaska Natives. Also provides funds for tribal and urban Indian Health programs.
What is a Share of Cost/Spenddown Medicaid plan?
Provides health insurance to person who meets Medicaid eligibility requirements but exceed the income/asset levels.
What is a SNF? What do we know about SNF billing for dialysis?
Skilled Nursing Facility
The services are excluded from SNF consolidated billing for it's inpatients.
What is a Medigap plan?
Also referred to a Medicare Supplement. A commercial plan that helps pay for the out-of-pocket cost not covered by Original Medicare (Part A/B).
What is an Exchange Plan?
An individual policy purchased from the commercial insurance. These plans DO NOT coordinate with Medicare.
On-Exchange: Purchased thru a federal site, person must have SSN to apply
Off-Exchange: Purchased from insurance companies website, person does not need SSN to apply
What type of plans are available for active duty or retried service members and their families? What type of plan is available for disabled veterans?
Tricare/Champ VA- Insurance plans for service members/family.
Veterans Administration- Authorization obtained from VA Hospital to agree to pay for services rendered by dialysis provider.
What is a Medicaid Assigned Plan?
Federally and state funded programs where Medicaid benefits are assigned to a commercial plan.
When would DaVita bill a Prison/Jail?
If a patient is incarcerated they loss Medicare/Medicaid plans and institution that they are incarcerated in will be responsible for paying for services.
Incarceration is anything that is court ordered (halfway house, rehab, behavioral institute, etc.)
For Medicare ESRD Entitlement when is the waiting period waived? If the waiting period is not waived, how long is it?
If PD/Home training is received within the first 3 months of the FDODE. If no self training is received the Medicare waiting period will be 3 months.
What is a SHOP Plan?
Type of EGHP that is purchased by an Employer through and exchange site. Designed for employers with less than 100 employees. These plans do coordinate with Medicare.
What is a Dual Special Needs Program?
Also called a DSNP or Dual Plan. Type of Medicare Advantage Plan that works with Medicaid plan, meaning person qualifies for both Medicare and Medicaid. Plans coordinate to offer additional benefits or services for those who qualify.
What is a Emergency Medicaid?
Also called EMA. Provides coverage for low income individuals that meet Medicaid requirements but are undocumented without citizenship.
When is Hospice billed? What happens to Medicare Advantage plan if a person enrolls in Hospice?
If persons hospice diagnosis is ESRD, hospice facility may be responsible for reimbursing for dialysis services.
Medicare Advantage plan cannot be billed once person enrolls in Hospice, traditional Medicare will be billed for services rendered.