Chapter 13 Flashcards
Chapter 13
Senior Needs
Medicare
Introduced in 1965 Medical Care coverage for 65 an above, or have been on social security for 2 years, or suffer from end stage renal disease.
Enrollment - 3 months before and after turning 65. General Enrollment begins next year during first quarter.
Part A - Hospital (Inpatient), deductible, Part B - Medical Insurance (Outpatient)
Part A
Hospitalization Post-Hospital Skilled Nursing Facility Home Health Care Hospice Care Blood after first (3 pints)
Part B
Medical Insurance and is optional
Medical Expense - doctor visits outpatient and inpatient, medical supplies, physical and speech therapies, and diganostic outside.
Clinical Laboratory Services
Home Health Care
Outpatient Hospital Treatment - necessary diagnosis and treatment
Blood - after first 3 pints
Medicare
An amendment to our Social Security Program in 1965 by Congress resulted in the Medicare program. For those 65 and older, and those with end stage renal disease.
Aged 65
SSDI
ESRD
Health and Human Services, individual insurers handle the paperwork, review claims, handle claim payments, and work to prevent payment of claims when Medicare is the secondary insurer. If one is age 65 or over and he/she or his/her spouse works, Medicare may be the secondary insurer to any employer group health plan he/she participates in.
Medicare Cont.
Group health plans with 20 or more employees is primary to Medicare and pays first. If the employer’s plan doesn’t pay all of one’s expenses, Medicare may pay secondary benefits for Medicare covered services to supplement the amount paid by the group plan.
Employers who have 20 or more employees are required to offer the same health benefits, under the same conditions to employees age 65 or over and to employees’ spouses who are 65 or over, as offered to the younger employees and spouses. If an employee is disabled and on Medicare, he/she is to receive the same offer as all other employees.
Medicare Enrollment
There are 2 basic enrollment periods for Medicare Parts A and B.
Initial Enrollment Period
General Enrollment Period
Initial Enrollment Period
lasts 7 months and begins on the first day of the 3rd month before one is eligible for Medicare and ends on the last day of the 3rd month following the month in which one is eligible for Medicare.
General Enrollment Period
From January 1 to March 31 each year in which one can enroll for Medicare if he/she did not enroll during the initial enrollment period. If one enrolls during the general enrollment period, coverage will begin the following July.
Medicare Part C Advantage and D
The open enrollment period provides Medicare beneficiaries with one opportunity to enroll in, disenroll from, or change a Medicare Advantage plan. This is also called the annual enrollment period.
Open Enrollment Period is typically November 15-December 31 each year. Becomes effective the month after the change is made.
Only those that are eligible to enroll in a Medicare Advantage Plan may make a change during the Open Enrollment Period. Beneficiaries may not add or drop Part D coverage during the Open Enrollment Period. Those who already have drug coverage can only change to another option with drug coverage. Those who do not have drug coverage may not change to an option that provides drug coverage.
Special Enrollment Period
SEP - allows beneficiaries to make an enrollment change outside of the other enrollment periods. Beneficiaries who delay enrolling in Part B because they are covered by employer-sponsored health insurance as an active worker or as a dependent of an active worker are not limited to enrolling in Part B during the GEP have a SEP that runs 8 months from the time they or their spouse retire or lose their health insurance. Part B coverage starts the month after the election is made, and no late premium penalty is assessed.
A numbef or SEPs exit for Medicare Advantage and Prescription Drug Plans (PDP) enrollment and disenrollment.
Beneficiaries who move into, reside in, or move out of a nursing home may also have a SEP. Individuals who are eligible for Medicare and Medicaid have an SEP that allows them to change Part D drug plans at any time.
Certification of Providers
Hospitals and other providers of health care that wish to participate in the Medicare Program must be licensed by the state. Medicare will not pay any services rendered by a provider that is not certified.
Effective in 1999
Medicare recipients who were carrying both Parts A and B became eligible for other health care options provided they lived within a service area of an alternative health plan. These alternative plans, effectively managed health care, are known as Part C- Medicare Advantage (formerly Medicare + Choice). As part of the premium paid for Part B, or for a possible additional charge, Medicare pays the Medicare Advantage alternative health plan a lump sum to oversee the health care services of the enrolled participants. The services provided by these plans may differ by degree of choice of providers, out-of-pocket expenses, and extra benefits, but all must provide basic Medicare covered services.
The Department doesn’t have to approve Medicare Material provided by the U.S. government prior to use for solicitation.
When Medicare recipients have a benefit change, they receive a notice of Medicare benefits change including coverage and/or premium changes.
Medicare Exclusions
Long Term Care Custodial Care Homemaker Services Dental Care Private Nursing Cosmetic Surgery Routine Eye Care/Hearing Aid Experimental or Alternative Medicines or Procedures.
Part A - Hospital Insurance (Inpatient)
Part A is premium free to those who fully qualify through Social Security or railroad retirement or government employment (financed by the payroll tax, FICA).
People under age 65 who have been disabled for 24 months and are receiving Social Security disability benefits qualify for Medicare and those over age 65 who do not qualify through Social Security, railroad retirees, or government employees may receive benefits for Part A coverage by paying monthly premiums.
The deductible is applied on a per benefit basis.
Part A Claim payments are made directly to the provider for any of the 5 major services received during a benefit period. Benefit period begins on the first day of hospitalization. It ends after a person has beenn out of the hospital or skilled nursing facility for 60 consecutive days or remains in a skilled nrsing facility without skilled care for 60 consecutive days. Part A provides an aggregate of 190 days of lifetime inpatient psychiatric care.
Inpatient Coverage Hospitalization
This means the services provided while admitted as a patient in a hospital under doctor’s orders. Such services include:
Bed and board
Nursing services and other related services
Use of hospital and CAH facilities
Medical Social Services
Drugs, Biologicals, supplies, appliances, and equipment.
Certain other diagnostic or therapeutic services.
Medical or surgical services provided by certain interns o residents in training.
Ambulance and transportation services.
Post Hospital Skilled Nursing Facility Care
To qualify, one must have been hospitalized for at least 3 days, enter a Medicare approved facility generally within 30 days after hospital discharge and meet other program requirements. After 20 days of skilled nursing care, the flat amount of coinsurance is paid through the 100th day. At that time, the patient must pay 100% of the cost.
Home Health Care
Medically necessary skilled care, home health aide services, nurses’ visits, medical supplies, for a limited, specified time.
Hospice Care
Full scope of pain relief and support services available to the terminally ill. Hospice includes a family counseling benefit.
Blood
Except the first 3 pints per benefit period/annually.
Benefit Period
A benefit period begins the day a person is admitted to a hospital (or under certain circumstances, a skilled nursing facility). The benefit period ends when the person has not received hospital or skilled nursing care for 60 days in a row. At that time, a new benefit period begins. There is no limit to the number of benefit periods a person can have.
Deductibles
Because Medicare is an insurance program, a person has deductibles for which he is responsible. For the first 60 days of hospitalization there is an initial deductible of $1,156 in 2013 but no copayment.
Copayments
After 60 days of hospitalization, a daily copayment is charged in the following amounts,
Days 61-90: $289
Days 91-150: $578
Over 150 Days: All costs by person.
Medicare B
Outpatient
Part B is optional and offered to all applicants when they become entitled to Part A either by qualification or premium. Enrollment dates for Part B are the same as for Part A. However, if a person enrolls in Part B during the Open Enrollment Period of January 1 through March 31, coverage will not begin until July 1. All part B recipients pay a monthly premium, $99.00.
Part B Major Services
Medical Expense Clinical Laboratory Services Home Health Care Outpatient Hospital Treatment Blood
Medical Expense
physician services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, ambulance services.
Clinical Laboratory
Blood tests, biopsies, uralysis.
Home Health Care
Skilled care, home health aide, medical supplies, personal residence.
Outpatient Hospital Treatment
reasonable and necessary services for the diagnosis or treatment of an illness or injury.
Blood
Except first 3 pints. Prescription Drugs not covered under Part B.
Part B payments
Are based on a national fee schedule. Medicare usually pays 80% of that amount. Part B has an annual deductible and requires a copayment.
Claim Payments
Medicare Assignment - must be filed within one year or Medicare will not pay. Healthcare providers and suppliers must be contracted by medicare.
Medicare Non-Assignment - Provider doesn’t accept amount and may charge 15% more. Beneficiary must make the claim. Doesn’t apply to Durable medical Equipment and some supplies. Part B doesn’t cover routine physical exams or dental services, but will cover kidney dialysis.
Fee For service
Medicare Private Fee for Service Plan is a Medicare Advantage Plan offered by a private company. Medicare pays a set amount of money every month to the private insurance company to provide health care coverage to people with Medicare on a Fee for Service Arrangement. Also, the insurance company, rather than Medicare, decides cost of services. Under the original Medicare, the government decided the amount health care providers would be paid for services.
Annual Deductible
Medicare Part B charges a yearly deductible that must be paid before Medicare will pay any covered services under Part B.
Coinsurance
This is the amount paid by the person once Medicare has paid its share. Once the deductible is paid, the person is responsible for 20% coinsurance for covered services.
Part C
Medicare Advantage plans include managed care, PPO, HMO, private fee for service and specialty plans. Medicare Parts A and B are both required to participate in Medicare Part C.
Joining a Medicare Advantage Plan requires premium payment for Part B as well as any premium required for additional benefits provided through medicare Advantage plan.
A medigap plan is unnecessary with MA as these plans generally cover many of the same benefits that a Medigap policy covers.
HMO’s have gatekeepers and may participate in POS, reduced benefits by going out the network. Medicare HMO - advanced prepayment of services. As a result there is a low or no deductible or copayment.
