Utilization Management: Medicare Beneficiaries
Medicare is the largest health insurance provider in the U.S. with more than 62 million people enrolled (Centers for Medicare and Medicaid Services [CMS], 2022b). Medicare offers four primary plans and multiple forms of supplemental or other insurance coverage for people who meet specific eligibility criteria. Some forms of Medicare must be paid, while some people are able to enroll in premium-free coverage plans. To ensure adequate coverage, anyone interested in Medicare services should discuss eligibility requirements, enrollment dates, and covered services with a knowledgeable professional. This course will describe the four parts of Medicare, including coverage, eligibility, and enrollment, and allows the learner to identify eligible Medicare participants.
The goal of this course is to equip nurses and social workers with knowledge of utilization management as it applies to Medicare beneficiaries in the acute care setting.
Medicare is the largest health insurance provider in the U.S. with more than 62 million people enrolled (Centers for Medicare and Medicaid Services [CMS], 2022b). Medicare offers four primary plans and multiple forms of supplemental or other insurance coverage for people who meet specific eligibility criteria. Some forms of Medicare must be paid, while some people are able to enroll in premium-free coverage plans. To ensure adequate coverage, anyone interested in Medicare services should discuss eligibility requirements, enrollment dates, and covered services with a knowledgeable professional. This course will describe the four parts of Medicare, including coverage, eligibility, and enrollment, and allows the learner to identify eligible Medicare participants. The goal of this course is to equip nurses and social workers with knowledge of utilization management as it applies to Medicare beneficiaries in the acute care setting.
American Nurses Credentialing Center
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses will receive 1.00 Nursing Contact Hours after successfully completing this course.
Arkansas State Board of Nursing
Arkansas State Board Of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
Association of Social Work Boards
As a Jointly Accredited Organization, Relias LLC is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Relias LLC maintains responsibility for this course. Social workers completing this course receive 1.00 General continuing education credits.
Course Delivery Format: Asynchronous Distance Learning-interaction includes quizzes with questions and answers, post-tests. This module is Reading-Based Online.
Commission for Case Manager Certification
This program has been pre-approved by The Commission for Case Manager Certification to provide 1.0000 hours of continuing education credit to CCM® board certified case managers.
District of Columbia Board of Nursing
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.00 contact hours for participating in this course.
Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling
Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling (CEBroker Provider #50-290)
This activity is approved for 1.00 contact hours.
Florida Board of Nursing
Florida Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Georgia Board of Nursing
Georgia Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Kentucky Board of Nursing
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Michigan Board of Nursing
Michigan Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Mississippi Board of Nursing
Mississippi Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
North Dakota Board of Nursing
North Dakota Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
Ohio Social Worker Board
Ohio Counselor, Social Worker and Marriage and Family Therapist Board Provider #RSX091903 (CEBroker Provider # 50-290)
This activity is approved for 1.00 contact hours.
South Carolina Board of Nursing
South Carolina Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
South Carolina Board of Social Work Examiners
South Carolina Board of Social Work Examiners (CEBroker Provider 50-290)
West Virginia Board of Registered Nursing
West Virginia Board of Registered Nursing (CEBroker Provider #50-290)
Nurses will receive 1.00 contact hours for participating in this course.
West Virginia Board of Social Work
West Virginia Board of Social Work (CEBroker Provider #50-290)
Describe coverage, eligibility, and enrollment for the most common Medicare plans.
Differentiate concepts of other Medicare payment plans and notices.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Medicare Plans, Premiums, and Participation
What is Medicaid?
What is Medicare?
Medicare Part A
Medicare Part B
What Is Not Covered by Medicare Parts A and B?
Medicare Part C
Medicare Part C and ESRD
Medicare Part D
Premiums
High Income Beneficiaries
Section 3: Medicare Eligibility and Enrollment
Eligibility Overview
Enrollment Overview
Medicare Part A
Medicare Part B
MA Plans
Medicare Part D
Section 4: Supplemental Plans and Medicare Notices
Medicare Supplemental Insurance
Medicare Savings Program (MSP)
Outlier Payments
Other Types of Medicare Plans
Conditions for Coverage (CfCs) and Conditions of Participation (CoPs)
Medicare Notices
Section 5: Clinical Vignette
Section 6: Conclusion
Course Summary
Course Contributors
Resources
References
Cathryn Ayers, RN, MSN has nearly 10 years of critical care experience. She was active in multiple committees to improve patient safety, executed staff education activities, and managed the new graduate orientation program for those entering intensive care units. Cathryn obtained a license for massage and bodywork therapy in 2012 and graduated from the University of North Carolina at Greensboro in 2016 with a Master of Science in Nursing Education. She has provided telephonic case management services and developed program materials to facilitate positive outcomes for people with rare conditions across the United States. Cathryn has a passion for teaching and helping others to be their best.Subject Matter Expert: Shalla Newton, MSN, RN, NE-BC
Shalla is a subject matter expert (SME)/writer for Relias. She completed her BSN and two undergraduate degrees with top honors from the University of Wisconsin-Madison. Shalla earned her dual MSN degrees from Johns Hopkins University with top honors. She also maintains her post-baccalaureate nurse educator certificate (NE-BC). Shalla’s tenure spans over 20 years of cross-functional leadership and direct clinical roles in healthcare, biopharma/biotech, government affairs, managed care/market access, nonprofit patient advocacy, and research. Her subject matter expertise is in rare, orphan, and complex diseases. Her sub-expertise is in immune-mediated diseases (rheumatology and immunology), genetics, neurology, hematology/oncology, several pediatric diseases, population/public health, and larger systemic healthcare affairs. Shalla is a published author with leading rare disease experts and a global speaker. She also sits on scientific, advocacy, and legislative advisory boards. She has led national advocacy and disease awareness campaigns, including speaking before congress, leading to the first-in-class rare disease biologic approval and investigative treatment protocols.
The target audience for this course is: Nurses; Social Workers; in the following settings: Acute Care Facility.
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
