Chapter 11: Senior Needs Flashcards
Medicare
A federal health insurance program providing coverage to persons of any age who have been:
- Diagnosed with chronic or permanent kidney failure, or End Stage Renal Disease
- Received Social Security Disability Income for at least 24 consecutive months
**Medicare eligibility remains at age 65, even though full Retirement Age for retirement benefits has increased.
Secondary Payor
If 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.
If employer’s plan does not pay all of one’s expenses, Medicare will pay secondary benefits for Medicare covered services to supplement the group plan benefits.
Primary Payor
A Group Health plan with 20 or more employees is primary to Medicare and pays first.
Employers who have 20 or more employees are required to offer the same health benefits and under the same conditions to employees and spouses age 65 or over, as they offer to younger employees and spouses.
The “Original” Medicare Program
Consisted of two parts: Part A and Part B. Both parts are provided by the government for basic hospital and medical expense coverage, including amounts that the recipient must pay out-of-pocket, such as deductibles and coinsurance.
Current Medicare Coverage
Consists of four parts:
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
Medicare Enrollment
Individuals are required to enroll in Medicare Parts A and B for coverage to begin. The following enrollment periods apply:
- Initial Enrollment Period
- General Enrollment Period
- Medicare Open Enrollment
- Special Enrollment Period
Initial Enrollment Period
- Lasts 7 months
- Begins 3 months before month of individuals 65th birthday
- Ends 3 months after the month following when the individual turned 65
- *The actual month of eligibility is the month of the individual’s birthday
General Enrollment Period
Provides a make-up period from 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.
Medicare Open Enrollment
Occurs every year from October 15 - December 7 and provides all individuals the chance to make changes to their Medicare coverage if needed.
Special Enrollment Period
Begins when a person 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 8 months and allows an individual the opportunity to enroll in Medicare Part B without incurring a penalty for failing to enroll at age 65.
Part A - Hospital Insurance Plan (Inpatient)
- Premium Free for those who qualify
- Deductible/Copayments per benefit period
- Benefit period begins first day of hospitalization
- Benefit period ends after patient out of hospital or skilled nursing facility for 60 consecutive days
- Inpatient hospitalization in a semiprivate room, miscellaneous hospital expenses, drugs while there
- Post-hospital skilled nursing facility care: must have been hospitalized for minimum of 3 days prior, and admitted to facility within 30 days of discharge
- Home health care: medically necessary skilled care, nurses’ visits, supplies
- Hospice care: full scope of pain relief and support to the terminally ill
- Blood: covered inpatient except for the first 3 units annually
Part B - Medical Insurance Plan (Physicians, Surgeons, and Outpatient)
- Optional and offered to applicants who become eligible for Part A
- Pay a monthly premium
- Provides benefits for:
- Medical expense: physician services, physical therapy, diagnostic tests
- Clinical lab services: blood tests, biopsies
- Home health care: medically necessary skilled care, supplies
- Outpatient hospital treatment: reasonable and necessary services for treatment
- Blood covered as outpatient after 3 pints annually
Part B Exclusions
- Prescription drugs, unless administered at an outpatient medical facility
- Care received outside the United States
- Routine dental care, including dentures
- Routine foot care
- Long-term care, including private or custodial nursing care, in any setting
- Hearing and eye exams
- Acupuncture
- Cosmetic surgery
Appeal
If an insured disagrees with a decision on the amount Medicare will pay on a claim, they have the right to appeal the decision.
Assignment
The claim is paid directly to the doctor or provider. Medicare approved providers have agreed to accept Medicare assignment and must accept Medicare’s payment as payment in full (not including any patient coinsurance).
Certification of Providers
Hospitals and other providers of health care that wish to participate in the Medicare program must be licensed by the state and certified by Medicare. Medicare will not pay for any services rendered by a provider that is not certified.
Claim
A request for payment that is submitted to Medicare or other health insurance when the patient gets items and services that they believe are covered.
Durable Medical Equipment
Certain medical equipment, like a walker, wheelchair, or hospital bed, that is ordered by a doctor for use in the home.
Excess Charge
If one has Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.
Limiting Charge
In Original Medicare, the highest amount that can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment.
Medicare-approved Amount
In Original Medicare, this is the amount a doctor or suppler that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and the recipient is responsible for the difference.
Medicare Summary Notice (MSN)
A notice you get after the doctor or provider files a claim for Part A or Part B services in Original Medicare. It explains what the doctor or provider billed for, the Medicare-approved amount, how much Medicare paid, and what the patient must pay.
Nonparticipating Provider
A provider who does not accept assignment.
Participating Provider
A provider who agrees to accept assignment and charges Medicare-approved charge.
