Chapter 11 Flashcards
Medicare Eligibility
Federal health insurance program that was originally designed to provide hospital and medical insurance primarily for citizens and legal residents age 65 or over
Expanded to legal residents of ANY AGE:
- diagnosed with chronic/permanent kidney failure or end stage renal disease
- received social Security disability for at least 24 consecutive months
Medicare Products
Consist of 2 parts. Both are provided by government for basic hospital/medical expense coverage
A- hospital insurance provided by fed government
B- medical insurance/outpatient exp provided by fed government
C- Medicare advantage plan sub part A&B into managed care plan offered by private insurance providers in place of original Medicare
D- prescription drug offered by private insurance providers
Medicare Enrollment Periods
Age 65- Medicare part A is mandatory for all citizens and legal residents. Enrollment is automatic and coverage is premium free for this fully insured by social security
Initial enrollment period
Last 7 months and begins 3 months before the month of an individual 65 birthday and ends 3 months after turned 65
General enrollment period
Open enrollment period from Jan 1 to March 31 each year for those who did not enroll in Medicare part B when they first became eligible
Special Enrollment
Begins person past age 65, who is no longer covered by the employer sponsored group health plan. Period last 8 months and allows individual opportunity to enroll in Medicare part B without incurring the lifetime premium penalty for failing to enroll at age 65
Excess charge
Difference between the approved amount and the actual charge
Participating Providers
Agreed to accept Medicare assignment, means they must accept the Medicare approved amount as payment in full, which includes any patient deductible or coinsurance
Medicare approved amount
Amount doctor or provider that accepts assignment can be paid, which may be less than actual amount a doctor or supplier charges.
Claim is paid directly to provider
Nonparticipating provider
One who does not accept assignment, legally permitted to charge an amount higher than the Medicare-approved amount. Bill sent to patient. Patient must submit claim form, to the carrier responsible for paying Medicare claims
Hospital Insurance (inpatient)
Medicare part A is financed by payroll and FCIA contributions and is premium-free to eligible individuals who qualify through social Security
PartA provides coverage for medically necessary inpatient hospital related charges, skilled nursing, home healthcare.
Payments made directly to provider
Requires deductible insurance
Benefit period - part a
Begins first day the insured enters the hospital after being enrolled in Medicare and ends once the insured has bee. Out of hospital for 60 consecutive days
Inpatient hospitalization
Part A provides coverage for up to 90 days per benefit
Medicare pay 100% of cover charges day 1-60
Insured responsible for co pay day 61-90
NONRENEWABLE LIFETIME RESERVE DAYS= hospitalization beyond 90 days, coverage with higher daily copayment
Part B- medical insurance
Optional coverage- offered to all applicants when they become eligible for part A
Automatically enrolled in part B when they initially enrolled in Part A unless specifically choose not to be enrolled
Requires to pay monthly premium
Part B pays 80% of covered expenses after an annual deductible has been met. The insured pays 20% coinsurance with no max out of pocket
Part C- Medicare Advantage
Part C plans are offered by private insurance companies that contract with Medicare to provide both part A/B
Part C is a substitute for original Medicare
