Ch 8 Medicare and long-Term Care Insurance Flashcards
The insurance age at the time the policy is issued or renewed
Attained age
A period of time during which benefits are paid under the policy
Benefit period
Sharing of expenses between the insured and the insurance company through deductibles, co-pays and coinsurance
Cost sharing
A person enrolled in a health insurance plan, and insured (doesn’t include dependence of the insured)
Enrollee
a prepaid medical service plan in which specified medical service providers contract with the HMO and which focuses on preventative care
Health maintenance organization (HMO)
A provider who enters into contractual arrangement with other providers to provide medical services to the networks subscribers
Network provider
A cash or insurance benefit received via policyholder who no longer wishes to make payments after making premium payments for at least a minimum period
Nonforfeiture benefit
a document required in all health insurance policies that provides a full coverage disclosure to the applicant
Outline of coverage
Part A is ________________; Part B is _________________.
Hospital insurance; medical insurance.
Medicare part C expand original Medicare benefits to private health insurance programs
True
After the initial benefit limit is reached, the prescription drug benefit plan will pay 75% of all generic and brand-name drug cost.
True
Medicare supplement plans are sold through private insurers, not federal health insurance programs.
True
All Medicare supplement plans must offer the core benefits available in Plan A.
True
Anyone over the age of 65 may choose to either keep the employers group health coverage or elect coverage through Medicare.
True
LTC policies must be guaranteed renewable
True
Skilled care and intermediate care requires the assistance of medically licensed personnel. Custodial care maybe administered by non-medical personnel.
True
Hospital insurance, finance through payroll tax (FICA)
Part A
Coverage:
- inpatient hospital care
- skilled nursing facility care
- home health care
- hospice care
Medical insurance, finance by insurance and general revenues
Part B
- optional to those who enroll in Part A
- doctor services
- outpaitent hospital services
- home health visits
- other medical and health services
Medicare advantage, allows for receipt of healthcare services through available provide organizations
Part C
- requires enrollment in parts A and B
- Provided by an approved HMO or PPO
Prescription drug coverage
Part D
- Optional coverage through private prescription plans that contract with medicare.
For individuals eligible for Medicare coverage to continue to work, the employers health plan will be primary coverage while Medicare would be secondary coverage
Primary, secondary payor
- Referred to as Medigap
- policies issued by private insurance companies to fill in gaps in Medicare
- open enrollment period of six months
Basics
Medicare supplement policies
Plan a core benefits, such as coinsurance/copayment; additional pate hospital cost; hospice care coinsurance/copayment; part B coinsurance/copayment; 3 pints of blood other parts a and B
- plans B – 10: core benefits + various additional benefits
Coverage
Medicare supplement policies
Employer Group Health Plans
Disabled employees under age 65, employees with kidney failure, individual age 65 or older
Medicaid
- medical care for those whose income and resources are insufficient
- Federal and state funded
Daily nursing and rehabilitation caper divided by medical personnel
Skilled care
Occasional nursing or rehabilitative care provider for stable conditions that require daily medical assistance on a less frequent basis than skilled nursing care
Intermediate care
Care for persons activities of daily living provided in an institutional setting or in the patient’s home
Custodial care
Provided by registered nurses, license practical nurses, license vocational nurses, or community-based organizations like hospice in one’s home
Home healthcare
Provided by the insured resides in a retirement community
Residential care
Provides for functionally impaired adults unless in a 24 hour basis
Adult daycare
Provide relief to the family caregiver; adult daycare centers may also provide this type of relief
Respite care
Provides help with non-medical daily activities
Assisted living
Long term care required provisions
Must be guaranteed renewable
- must offer inflation protection
- free look. 30 days
- pre-existing conditions exclusion - no more than six months
- must cover Alzheimer’s disease
- disclosure requirements - outline of coverage and policy summary
Long-term care coverage and benefits
- 12 consecutive months
- elimination period of 30 days or more
- benefit period of 2 to 5 years; some offering lifetime coverage
- longer benefit. Result in higher premium
- trigger in ability to perform ADLs (usually 2-3)
Who is eligible for Medicare?
People age 65 and older, those entitled to Social Security disability income benefits for two years, are those with permanent kidney failure (regardless of age)
What plans fill in the gaps in Medicare coverage?
Medicare Supplement Policies, or Medigap
What is the name of the benefits provided by Medicare supplement part A?
Core benefits
