CMS Treatment Planning & Management 2 — Questions and Answers
Question 1: A Medicare beneficiary with chronic kidney disease stage 4 is referred for dialysis planning. Which Medicare benefit covers routine dialysis treatments once ESRD is established?
- Medicare Part A only
- Medicare Part B only
- Medicare Part A and Part B (Correct answer)
- Medicare Part D
Correct answer: Medicare Part A and Part B
Medicare Part A covers inpatient dialysis and Part B covers outpatient dialysis services for ESRD beneficiaries.
Question 2: When coordinating a treatment plan for a Medicare Advantage enrollee, what must the CMS specialist verify before authorizing a specialist referral?
- The specialist accepts Medicare assignment
- The specialist is in-network or prior authorization is obtained (Correct answer)
- The beneficiary has met their Part B deductible
- The referral is submitted within 30 days of diagnosis
Correct answer: The specialist is in-network or prior authorization is obtained
Medicare Advantage plans use network-based care, so the specialist must be in-network or the plan's prior authorization process must be followed.
Question 3: A physician wants to place a patient in a skilled nursing facility following a 4-day hospital stay. Does Medicare Part A cover this SNF admission?
- Yes, because 4 days meets the 3-day inpatient requirement (Correct answer)
- No, because the minimum hospital stay is 5 days
- Yes, but only for 20 days without cost-sharing
- No, because SNF requires a separate Part A election
Correct answer: Yes, because 4 days meets the 3-day inpatient requirement
Medicare requires at least a 3-day inpatient qualifying hospital stay, so a 4-day stay satisfies this requirement for SNF coverage.
Question 4: Under Original Medicare, which entity is primarily responsible for managing a beneficiary's overall treatment plan across multiple providers?
- CMS directly assigns a care coordinator
- The beneficiary's primary care physician typically coordinates care (Correct answer)
- A Medicare Administrative Contractor assigns a case manager
- The Social Security Administration oversees treatment plans
Correct answer: The beneficiary's primary care physician typically coordinates care
Under Original Medicare's fee-for-service model, the primary care physician generally coordinates care without a formal care manager mandate.
Question 5: A patient recovering from a stroke requires physical, occupational, and speech therapy in an inpatient rehabilitation facility. What Medicare benefit covers IRF stays?
- Medicare Part B outpatient therapy benefit
- Medicare Part A inpatient benefit (Correct answer)
- Medicare Part C supplemental benefit only
- Medicare Part D with prior authorization
Correct answer: Medicare Part A inpatient benefit
Inpatient rehabilitation facility stays are covered under Medicare Part A as an inpatient benefit.
Question 6: A CMS specialist is helping a beneficiary transition from inpatient to home health care. What eligibility criterion must the patient meet for Medicare home health coverage?
- The patient must have been hospitalized for at least 3 days
- The patient must be homebound and require skilled care (Correct answer)
- The patient must enroll in a Medicare Advantage plan
- The patient must be under age 75 to qualify for home health
Correct answer: The patient must be homebound and require skilled care
Medicare home health coverage requires the beneficiary to be homebound and need skilled nursing or therapy services ordered by a physician.
Question 7: Which Medicare program model holds providers jointly accountable for the quality and cost of care for a defined patient population?
- Fee-for-service Medicare
- Accountable Care Organization (ACO) (Correct answer)
- Medicare Savings Program
- State Pharmaceutical Assistance Program
Correct answer: Accountable Care Organization (ACO)
ACOs coordinate care for Medicare patients and share in savings (or losses) based on quality and cost performance.
CMS Treatment Planning & Management 2
A Medicare beneficiary with chronic kidney disease stage 4 is referred for dialysis planning.
Which Medicare benefit covers routine dialysis treatments once ESRD is established?