Emergency Procedures & Response Flashcards

A Medicare beneficiary calls to report they were hospitalized as an observation patient for 3 nights but were told Medicare Part B applies rather than Part A. What should the specialist explain?

Answer: Observation status is an outpatient classification, so Part A inpatient benefits do not cover the stay

Observation status is an outpatient designation, meaning Part A inpatient hospital benefits do not apply even if the patient stays overnight.

During a natural disaster, a Medicare beneficiary cannot reach their primary care physician. Which Medicare program allows them to see any available provider without a referral during a declared federal emergency?

Answer: Medicare Advantage Disaster Waiver provisions

During a federally declared disaster, Medicare Advantage plans must activate disaster waiver provisions that allow enrollees to see out-of-network providers without referrals.

A beneficiary's Medicare Advantage plan denies an emergency room claim because the plan claims the visit was not a true emergency. Which standard protects the beneficiary in this situation?

Answer: The Prudent Layperson Standard

The Prudent Layperson Standard requires MA plans to cover emergency care based on the presenting symptoms a reasonable person would consider an emergency, not the final diagnosis.

A Medicare Part D enrollee needs a refill of a critical medication during a hurricane evacuation but is in a different state. Under emergency dispensing rules, what should the pharmacist do?

Answer: Dispense up to a 30-day emergency supply even without a new prescription if permitted by state law

CMS allows Part D plans to waive early refill restrictions and permit emergency dispensing of up to a 30-day supply during declared emergencies.

Which entity must a Medicare beneficiary notify first when appealing an emergency hospital stay denial from their Medicare Advantage plan?

Answer: The Medicare Advantage plan's internal appeals process

Beneficiaries must first exhaust the plan's internal appeals process before escalating to external review bodies such as the QIO.

A specialist receives a call from a beneficiary who was air-transported to a trauma center during an emergency. Under Original Medicare, how is air ambulance transport generally covered?

Answer: Under Part B as a medically necessary ambulance service

Medicare Part B covers air ambulance transport when ground transport would endanger the patient's health and it is medically necessary.

A Medicare beneficiary with a Medicare Supplement plan is treated at an out-of-state emergency room. How does their Medigap policy typically handle emergency care costs outside the U.S.?

Answer: Plans C, D, G, M, and N cover foreign emergency care up to $50,000 lifetime after a $250 deductible

Medigap Plans C, D, G, M, and N include a foreign travel emergency benefit covering 80% of costs after a $250 deductible, up to a $50,000 lifetime limit.