Emergency Procedures & Response Flashcards

A Medicare beneficiary enrolled in an HMO-type Medicare Advantage plan has a stroke while traveling in another state. After stabilization, the hospital wants to transfer them to a rehabilitation facility. Who approves this transfer?

Answer: The Medicare Advantage plan must authorize post-stabilization care transfers

After emergency stabilization, Medicare Advantage plans must authorize continued post-stabilization care, though plans cannot delay authorization unreasonably.

A beneficiary's home health agency cannot reach them after a declared hurricane. What CMS-required emergency preparedness activity should the agency have completed to address this scenario?

Answer: Developed and implemented a patient tracking and care coordination plan as part of their emergency preparedness program

CMS requires Medicare-certified home health agencies to maintain an emergency preparedness program that includes patient tracking and care coordination procedures.

Under Medicare's emergency care rules, what constitutes 'stabilization' that marks the transition from emergency to post-stabilization coverage?

Answer: When no material deterioration of the patient's condition is likely to result from transfer or discharge

EMTALA defines stabilization as the point at which the patient's condition is unlikely to materially deteriorate from a transfer or discharge.

A Part D enrollee needs insulin during a hurricane evacuation and their plan requires prior authorization. Under a CMS emergency declaration, what happens to the prior authorization requirement?

Answer: CMS can waive prior authorization requirements for Part D plans during emergencies, allowing dispensing without prior approval

During CMS-declared emergencies, Part D plans may be required to waive prior authorization, step therapy, and early refill restrictions to ensure medication access.

A Medicare beneficiary is transported by ground ambulance to the hospital but the ambulance is not enrolled in Medicare. Under what circumstances would Medicare still pay for this transport?

Answer: Medicare will pay if the transport was an emergency and no enrolled ambulance was reasonably available

Medicare may cover emergency ambulance transport from non-enrolled providers on an unassigned basis if no enrolled provider was reasonably available.

When must a Medicare Advantage plan respond to a request for expedited appeals related to a denial of ongoing emergency inpatient services?

Answer: Within 72 hours

For expedited appeals involving urgent care or continuing emergency services, Medicare Advantage plans must respond within 72 hours of receiving the request.

A beneficiary enrolled in a Medicare Cost Plan seeks emergency care while temporarily in a state not covered by the plan. How are these emergency services reimbursed?

Answer: Original Medicare (Part A and B) reimburses emergency services received outside the Cost Plan's service area

Medicare Cost Plans cover emergency and urgently needed care anywhere in the U.S., with Original Medicare rules applying to services received outside the plan's service area.