Chapter 05

Question 1

Who can Qualify for Medicare

Answer 1

■ people age 65 or over
■ Diagnosed with chronic or permanent kidney failure, or End Stage Renal Disease
■ Received Social Security Disability Income for at least 24 consecutive months

Question 2

What is e Centers for Medicare & Medicaid Services (CMS)

Answer 2

a separate department
within the Department of Health and Human Services Administration, and is responsible for
reviewing and approving Medicare claims.

Question 3

Primary vs. Secondary Payor

Answer 3

If an individual is age 65 or over and continues to work, Medicare is usually the secondary
insurer to any employer group health plan the individual participates in.

Groups above 20 has Med as secondary and groups smaller have Med as primary

Question 4

What are the Medicare Products

Answer 4

■ Part A – Hospital Insurance provided by the federal government
■ Part B – Medical Insurance and outpatient expenses provided by the federal government
■ Part C – Medicare Advantage plan combines Part A and Part B into a managed care plan
offered by private insurance providers
■ Part D – Prescription drug coverage offered by private insurance providers

Question 5

When is Initial Enrollment

Answer 5

s 7 months and begins 3 months before the month of an
individual’s 65th birthday and ends 3 months after the month following when the individual
turned age 65. The actual month of eligibility is the month of the individual’s birthday.

Question 6

e General Enrollment Period

Answer 6

January 1 to March 31 each
year for those who did not enroll in Medicare Part B when they first became eligible. For
individuals enrolling during the general enrollment period, coverage begins on July 1.

Question 7

Medicare Open Enrollment

Answer 7

October 15 - December 7 and provides

all individuals the chance to make changes to their Medicare coverage if needed.

Question 8

Special Enrollment Period

Answer 8

past age 65, who was covered by an
employer-sponsored group health plan, is no longer covered by the plan (whether the person
elects COBRA continuation or not). This period lasts eight months and allows an individual the
opportunity to enroll in Medicare Part B without incurring a penalty for failing to enroll at age 65.

Question 9

What Does Part A Cover?

Answer 9

Hospital Insurance (Inpatient)

Question 10

What is Part A Benefit Period

Answer 10

first day the insured enters the hospital after being
enrolled in Medicare and ends once the insured has been out of the hospital for 60 consecutive
days.

Question 11

What Coverage is Provided for Inpatient Hospitalization

Answer 11

– Part A provides coverage for up to 90 days per benefit period.
Medicare will pay 100% of covered charges for days 1 - 60. The insured will be responsible for
a specified daily copayment for days<b> 61 - 90 >and Medicare will pay the balance. If the insured
is hospitalized beyond 90 days in a benefit period, 60 nonrenewable lifetime reserve days are
available for coverage with a higher daily copayment.
Once the insured is out of the hospital for 60 consecutive days, a new benefit period begins
which renews the 90 days of coverage and requires a new deductible. The lifetime reserve days
do not renew. If an insured uses the lifetime reserve days and is hospitalized longer than 90 days
in a benefit period, the out-of-pocket expense is 100%.
Medicare Part A includes the following coverage:
■ Semiprivate room and board
■ Operating room costs
■ Prescription drugs including anesthesia
■ Miscellaneous hospital services and supplies
■ Blood transfusions after the first 3 pints of blood</b>

Question 12

How Does Part A Mental Health Care Work

Answer 12

Same as Part A inpatient

Question 13

Part A: Skilled Nursing Care

Answer 13

Medicare Part A provides limited benefits for skilled nursing care following 3 days of hospitalization. The first 20 days are covered 100%. Days 21 - 100 are
covered except for a daily copayment. After 100 days of skilled nursing care, there is no additional benefit from Medicare and the insured pays 100%. Once there is a break from skilled care of 60 consecutive days, the skilled nursing care benefit is renewed.

(feeding tube, wound needs care, rehabilitate wound, requires nurse on staff or 24/7 care)

Question 14

Part A: Home Health Care

Answer 14

Medically necessary care following the release from the hospital, including
home health aide services, nurses’ visits, and medical supplies are covered.

Question 15

Part A: Hospice Care

Answer 15

Pain relief and support services provided to the terminally ill and their family
members is covered

Question 16

Part A Blood

Answer 16

There is a “deductible” amounting to the first 3 pints of blood administered per calendar
year. After the deductible is met, Part A will cover the cost of inpatient blood transfusions for the
remainder of the year.

Question 17

Part B Differences

Answer 17

Physicians, Surgeons (in and outpatient;
and Outpatient. Medicare Part B pays 80% of
covered expenses after an annual deductible has been met. The insured pays 20% coinsurance with
no maximum out-of-pocket.

Question 18

Part B Preventive Care Is

Answer 18

A one-time “Welcome to Medicare” preventive visit is covered along with
yearly “wellness’’ visits. In addition, Part B will cover vaccines and preventive screenings for
cancer and several other conditions.