CMS Emergency Procedures & Response 2 — Questions and Answers
Question 1: 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?
- Observation status means the hospital made an error and Part A should always apply
- Observation status is an outpatient classification, so Part A inpatient benefits do not cover the stay (Correct answer)
- The beneficiary should file an emergency appeal with CMS immediately
- Medicare Advantage overrides all observation status rules
Correct 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.
Question 2: 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?
- Medicare Supplement Plan G
- Medicare Part D Emergency Fill
- Medicare Advantage Disaster Waiver provisions (Correct answer)
- Medicare Special Needs Plan (SNP)
Correct 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.
Question 3: 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?
- The Treating Physician Standard
- The Prudent Layperson Standard (Correct answer)
- The Medical Necessity Doctrine
- The Prior Authorization Waiver
Correct 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.
Question 4: 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?
- Refuse to fill until the enrollee returns to their home state
- Dispense up to a 30-day emergency supply even without a new prescription if permitted by state law (Correct answer)
- Require a new prior authorization before dispensing any medication
- Refer the enrollee to the nearest hospital emergency room
Correct 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.
Question 5: Which entity must a Medicare beneficiary notify first when appealing an emergency hospital stay denial from their Medicare Advantage plan?
- The Social Security Administration
- The State Insurance Commissioner
- The Medicare Advantage plan's internal appeals process (Correct answer)
- The Office of Inspector General
Correct 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.
Question 6: 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?
- Under Part A as an inpatient hospital service
- Under Part B as a medically necessary ambulance service (Correct answer)
- Under Part D as an emergency supply benefit
- It is not covered under any Medicare part
Correct 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.
Question 7: 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.?
- All Medigap plans cover foreign emergency care up to $50,000 lifetime
- Plans C, D, G, M, and N cover foreign emergency care up to $50,000 lifetime after a $250 deductible (Correct answer)
- No Medigap plans cover foreign emergency care
- Only Plan F covers foreign emergency care with no deductible
Correct 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.
CMS Emergency Procedures & Response 2
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?