CHAA Payer Types and Coordination of Benefits (COB) 2 — Questions and Answers
Question 1: What is the primary difference between Medicare Part A and Medicare Part B coverage?
- Part A covers drugs and Part B covers hospital stays
- Part A covers inpatient hospital, skilled nursing, hospice, and home health; Part B covers outpatient services, physician visits, and preventive care (Correct answer)
- No difference between Part A and Part B
- Part A is for over 65, Part B is for under 65
Correct answer: Part A covers inpatient hospital, skilled nursing, hospice, and home health; Part B covers outpatient services, physician visits, and preventive care
Part A focuses on inpatient/facility care and Part B on outpatient/professional services.
Part A (Hospital Insurance) covers inpatient stays, skilled nursing, hospice, and some home health. Part B (Medical Insurance) covers physician services, outpatient care, preventive services, and durable medical equipment. The patient's status (inpatient vs. outpatient/observation) determines which Part applies.
Question 2: A 67-year-old working patient has both Medicare and an employer group health plan. Which is primary?
- Medicare is always primary for patients over 65
- The employer plan is primary if the employer has 20 or more employees (Correct answer)
- The patient chooses
- Both pay equally
Correct answer: The employer plan is primary if the employer has 20 or more employees
Under MSP working-aged rules, the employer plan is primary if the employer has 20+ employees.
The MSP working-aged provision applies to beneficiaries 65+ covered by an employer group health plan through current employment. If the employer has 20+ employees, the employer plan is primary. If fewer than 20 employees, Medicare is primary.
Question 3: What is Medicaid, and how does it differ from Medicare?
- They are the same program
- Medicaid is a joint federal-state program for low-income individuals; Medicare is federal for those 65+ or with certain disabilities (Correct answer)
- Medicaid is only for children
- Medicare is for low-income; Medicaid is for seniors
Correct answer: Medicaid is a joint federal-state program for low-income individuals; Medicare is federal for those 65+ or with certain disabilities
Medicaid is needs-based (income) while Medicare is entitlement-based (age/disability).
Medicare is federal for those 65+, those with disabilities after 24 months of SSDI, and those with ESRD or ALS. Medicaid is joint federal-state with income-based eligibility varying by state. Some qualify for both (dual-eligible).
Question 4: For a dual-eligible patient (Medicare and Medicaid), what is the COB order?
- Medicaid is always primary
- Medicare is primary; Medicaid is secondary covering cost-sharing amounts (Correct answer)
- Patient chooses
- Both pay simultaneously
Correct answer: Medicare is primary; Medicaid is secondary covering cost-sharing amounts
Medicare is always primary for dual-eligible patients; Medicaid covers deductibles and copayments.
Medicare pays first as primary. Medicaid pays second as payer of last resort, covering deductibles, copayments, and coinsurance. Dual-eligible patients should have zero out-of-pocket costs for Medicare-covered services.
Question 5: What is TRICARE, and which population does it serve?
- A dental-only plan
- The healthcare program for active duty military, veterans, retirees, and their families (Correct answer)
- A Medicaid managed care plan
- Only covers emergencies
Correct answer: The healthcare program for active duty military, veterans, retirees, and their families
TRICARE is the DoD healthcare system serving military members, retirees, and dependents.
TRICARE serves approximately 9.6 million beneficiaries. Plans include TRICARE Prime (HMO-style), Select (PPO-style), and For Life (supplemental for Medicare-eligible retirees, where Medicare is primary).
Question 6: What is subrogation in health insurance, and how does it affect patient access?
- Enrolling in a new plan
- The insurer's right to recover costs from a third party responsible for the patient's injuries, requiring access staff to identify accident-related visits (Correct answer)
- Only applies to auto insurance
- The patient's right to choose any provider
Correct answer: The insurer's right to recover costs from a third party responsible for the patient's injuries, requiring access staff to identify accident-related visits
Subrogation allows insurers to recover costs from responsible third parties.
Subrogation applies when injuries result from auto accidents, slip-and-fall incidents, workplace injuries, or other third-party liability. Patient access must ask about injury cause during registration to identify subrogation situations and determine proper billing order.
CHAA Payer Types and Coordination of Benefits (COB) 2
What is the primary difference between Medicare Part A and Medicare Part B coverage?