Chapter 13: Other Medicare Health Plans

Question 1

______ for _____-_____ _______ for the ____ (PACE) encompass coverages for:

Medical services,
Long-term care,
Social services, and
Prescription drug coverage.

Answer 1

Programs for All-Inclusive Care for the Elderly (PACE)

Question 2

PACE is for elderly and disabled individuals. Care is provided in a community setting, such as a nursing home. PACE is provided in states that have elected it as a _______ benefit.

Answer 2

Medicaid

Question 3

To qualify for Programs for All-Inclusive Care for the Elderly (PACE)?

Answer 3

Age 55 and above;
Resides in a PACE organization’s service area; and
State-certified as requiring nursing home care.

Question 4

______, also referred to as Title 19, is a dually funded welfare program through state and federal dollars for people who have limited incomes and resources to cover the cost of health care. Each state operates its own program through its Department of Public Welfare.

Answer 4

Medicaid

Question 5

TF: People that qualify for both Medicaid and Medicare are referred to as dual-eligible.

Answer 5

true

Question 6

Medicaid provides coverage for ____ ____ and _______ that Medicare only partially covers, including ____ ___ and ____ _____care.

Answer 6

Medical care and Services
Nursing Home and Home Health

Question 7

Medicaid was formed to cover the cost of health care for people with ____ _____

Answer 7

Limited Income

Question 8

In order to qualify for Medicaid nursing home and home health care benefits, an applicant must first pass the ____ _____, which verify that the applicant has _____ income and assets, and cannot afford the cost of their medical expenses.

Answer 8

Means Tests
Limited

Question 9

The Medicaid applicant must also be:

Answer 9

Disabled,
Blind, or
Over the age of 65.

Question 10

TF: Some assets are not included in the asset limitation tests, such as:

The applicant’s primary residence,
One vehicle, and
Wedding ring.

Answer 10

True

Question 11

TF: Individuals who qualify for public assistance are those with dependent children or who are:

Blind,
Disabled, or
Pregnant.

Answer 11

True

Question 12

TF: Medicaid pays for medical care that lower income individuals cannot afford, such as:

Physician’s fees,
Hospitalization,
Pregnancy, and
Maternity care.

Answer 12

True

Question 13

Individuals applying for Medicaid assistance must deplete or “____ _____” their financial resources to a specific minimum before receiving Medicaid benefits. The amount is established on a state-by-state basis. Individuals are permitted to keep some assets and income, including their primary residence.

Answer 13

Spend Down

Question 14

TF: An individual, whose spouse requires nursing home care, is not allowed to keep part of the couple’s financial resources.

Answer 14

false - the spouse IS allowed to keep part of their financial resources

Question 15

_____ _____ ____ receive funds from Medicaid to assist individuals in paying Medicare premiums. Some pay a portion of Medicare Part A and B deductibles and coinsurance.

Answer 15

Medicare Savings Programs (MSPs)

Question 16

Four types of Medicare Savings Programs:

____ _____ _____Program: helps pay for Part A and Part B premiums and deductibles, coinsurance, and copayments
____ ___-_____ ____ Program: helps pay Part B premiums only
_____ _______ Program: helps pay for Part B premiums only
____ ____ and ___ ____Program: helps pay Part A premiums only

Answer 16

Qualified Medicare Beneficiary (QMB)
Specified Low-income Medicare Beneficiary (SLMB)
Qualifying Individual (QI)
Qualified Disabled and Working Individuals (QDWI)

Question 17

TF: To be eligible for Medicare Savings Programs, a beneficiary must have Medicare Part A and have monthly income and resources below the listed amounts.

Monthly Income Limits:

QMB: $1,001/individual; $1,348/married filing jointly
SLMB: $1,197/individual; $1,613/married filing jointly
QI: $1,345/individual; $1,813/married filing jointly
QDWI: $3,962/individual; $5,329/married filing jointly

Answer 17

True

Question 18

True: MSP’s Resource Limits:
QMB, SLMB, and QI: $7,280/individual; $10,930/married filing jointly
QDWI: $4,000/individual; $6,000/married filing jointly

Resources include:
Money in checking and savings accounts,
Stocks and
Bonds.

Answer 18

True:

Question 19

TF: MSP’s Resources exclude:

An individual’s home,
Household items and furniture,
Vehicle,
Up to $1,500 for burial expenses, and
Burial plot.

Answer 19

True

Question 20

SS income benefits are paid by Social Security to individuals who: (3 items)

Answer 20

Have limited incomes
are disabled or blind
are age 65 or older

Question 21

SS Income is different from SS benefits. Income pays for a person’s: 3 things

Answer 21

Food
Shelter
Clothing needs

Question 22

TF: To be eligible for SSI benefits, an individual must meet all of the following:

Be a U.S. citizen, national, or eligible non-citizen;
Be a U.S. resident or a resident of the Northern Mariana Islands; Residents of Puerto Rico, Guam, American Samoa or the U. S. Virgin Islands are generally ineligible for SSI benefits; and
Must not leave the U.S. for more than one calendar month or 30 consecutive days.

Answer 22

True

Question 23

Medicare Supplement policies, or _____ policies, help cover certain costs not covered by Medicare, such as:

Deductibles,
Coinsurance, and
Actual charges in excess of what Medicare pays.

Answer 23

Medigap

Question 24

Medicare Supplement policies are not ____ ____ policies, meaning that they are not limited to covering only a ____ ____ or _____. Private insurers sell Medigap policies. Each Medigap policy must meet certain guidelines.

Answer 24

Limited Risk
Specific Event or Situation

Question 25

TF: Any person who is eligible for Medicare coverage is also eligible to enroll in a Medigap policy

Answer 25

True

Question 26

Who qualifies for open enrolment for Medigap policies?

Answer 26

A person must have Parts A and B to purchase a Medigap policy.
Open enrollment for Medigap policies spans a six-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Part B.
Once the Medigap open enrollment period begins, it cannot be delayed or reinstated.
Coverage may not be denied based on a person’s health status, claims experience, or pre-existing medical condition if an individual enrolls during the open enrollment period.

Question 27

TF: It is legal to sell a person a Medigap policy if they already have Medicare Part C coverage.

Answer 27

False - Ilegal

Question 28

TF: If an individual’s Medigap policy provides prescription drug coverage, then the individual cannot also have a Part D plan.

Answer 28

True

Question 29

TF: The NAIC developed standard Medigap policies. Medigap policies are identified by letters A through N, and these are the only Medigap policies permitted by law.

Plan A is required to be offered by any insurer offering Medigap policies.
However, insurers have the option of offering Plans B – N.
Each Medigap policy A – N must provide the same coverage, regardless of which insurer it is sold by.

Answer 29

True

Question 30

TF: Each Medigap policy insures one individual, so a married couple wanting Medigap coverage would require two separate Medigap policies. Each individual pays monthly premiums for Medigap coverage.

Answer 30

True

Question 31

TF: Medigap core benefits -
Part A copayments for approved hospital charges during the 61st through 90th day of hospitalization
Part A copayments for approved hospital charges for the 60 lifetime reserve days
Approved hospitalization costs for 365 extra days after all Medicare benefits have been exhausted
Coverage for the blood deductible (first three pints)
The 20% Part B coinsurance

Answer 31

True

Question 32

TF for Medigap policies: Core benefits are in Plan A, while B-N all contain the core benefits from Plan A, in addition to other benefits

Answer 32

True

Question 33

The loss ratio (total amount of benefits paid out compared to the total amount of premium dollars collected) for Medicare Supplement policies must be at least _____ for group contracts and ____ for individual contracts.

Answer 33

75%
65%

Question 34

Once a Medicare policy has been in effect for a period of _____ months, benefits cannot be limited or denied because the individual has pre-existing conditions. Pre-existing conditions are defined as conditions for which medical treatment or advice was received in the ____ months prior to the policy effective date.

Answer 34

6
6

Question 35

Individuals who become eligible to receive Medicaid benefits are permitted to suspend their Medicare Supplement policy if the request is made within ____ ____ of receiving Medicaid benefits for a maximum of ____ _____.

Answer 35

90 days
2 years

Question 36

_____ _____ policies are Medicare Supplement policies that are offered on a PPO basis. These policies tend to have lower premiums compared to Medicare Supplement policies.

Answer 36

Medicare Select

Question 37

Medicare Supplement policy rates can be based on the following three things:

Answer 37

Attained-age,
Issue-age, or
Community-rated pricing.

Question 38

With ____-_____ pricing, the price paid for a Medicare Supplement Plan is based on the insured’s current age, or the age of the insured when he or she “attained” the policy and the insured’s premiums will increase, as the insured gets older.

Answer 38

Attained Age

Question 39

Some Medicare Supplement Plans are based on ____-___ pricing, which means that the insurance company bases the cost of premiums on the age of the insured at the time of purchase or issue and premiums will not go up due to age.

Answer 39

Issue-Age

Question 40

With ____-____ pricing, Medicare Supplement Plans charge the same premium to all beneficiaries, regardless of their age and overall health condition.

Answer 40

Community Rated

Question 41

To be eligible for PACE, an individual must be:
Select one:
a. Age 50 or above and require nursing home care
b. Age 60 or above, live in a PACE service area, and require home health care
c. Age 55 or above, live in a PACE service area, and state-certified as requiring nursing home care
d. Age 40 or above and disabled

Answer 41

C

Question 42

Which of the following pays monthly income for food, shelter and clothing needs to individuals with limited incomes, are disabled or blind, or are age 65 and older?
Select one:
a. Social Security
b. Supplemental Security Income Benefits
c. Medigap
d. Medicare

Answer 42

B

Question 43

All the following statements about Medicare supplement policies are false, EXCEPT:
Select one:
a. Each standardized Medicare supplement policy must cover the basic benefits.
b. Medicare Supplement Plan A provides coverage for skilled nursing facility care.
c. Medicare Supplement Plan B provides coverage for skilled nursing facility care and at-home recovering care.
d. Three basic supplement policies are considered core plans.

Answer 43

A

Question 44

TF: Each standardized Medicare supplement must cover the basic defined benefits in Medicare Supplement Plan A, the core plan. Medicare Supplement Plan B covers basic benefits plus Medicare Part A deductible for hospitalization. Neither Medicare Supplement Plan A nor Plan B covers skilled nursing facility care or at-home recovery care.

Answer 44

True

Question 45

When is open enrollment for Medicare supplement policies?
Select one:
a. Open enrollment for Medigap policies spans a three-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B.
b. Open enrollment for Medigap policies spans a five-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B.
c. Open enrollment for Medigap policies spans a six-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B.
d. Open enrollment for Medigap policies spans a eight-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B.

Answer 45

C

Question 46

TF: Open enrollment for Medigap policies spans a six-month period beginning on the first day of the month in which the individual is age 65 or above and enrolls in Medicare Part B.

Answer 46

True

Question 47

Medicaid is operated on the:
Select one:
a. Federal level
b. Local level
c. State level
d. None of the above`

Answer 47

C

Question 48

A Medicare supplement policy must provide coverage Medicare Part A-eligible expenses for hospitalization:
Select one:
a. For the length of the illness
b. For the first year
c. From days 1 through 90
d. From days 61 through 90

Answer 48

D

Question 49

A contract designed primarily to augment reimbursement under Medicare for hospital, medical, or surgical expenses is:
Select one:
a. A Medicare supplement plan
b. An alternative health care plan
c. A separate coverages plan
d. An assisted living plan

Answer 49

A

Question 50

How is Medicaid funded?
Select one:
a. Federal tax only
b. Federal and state taxes
c. Premiums
d. State guaranty funds

Answer 50

B

Question 51

Medicaid will pay for all of the following, EXCEPT:
Select one:
a. Hospitalization
b. Pregnancy care
c. Maternity care
d. Cosmetic procedures

Answer 51

D

Question 52

Which of the following is a Medicare supplement additional benefit?
Select one:
a. Medicare Part A copayments for approved hospital charges for the 60 lifetime reserve days
b. Blood deductible
c. Medicare Part B deductible
d. Medicare Part A copayments for approved hospital charges during the 61st through 90th day of hospitalization

Answer 52

C

Question 53

TF: The core benefits include: Medicare Part A copayments for approved hospital charges during the 61st through 90th day of hospitalization; Medicare Part A copayments for approved hospital charges for the 60 lifetime reserve days; approved hospitalization costs for 365 extra days after all Medicare benefits have been exhausted; coverage for the blood deductible (first three pints); and the 20% Medicare Part B coinsurance.

Answer 53

True

Question 54

Understanding Medicare and employee group health plans:

Medicare is primary if the individual is retired.
Medicare is secondary if the individual is currently employed and insured under his or her own or their spouse’s employer coverage.
Medicare is secondary for the first 30 months an individual has ESRD.
Medicare is secondary to no-fault insurance, liability, lung benefits, and Workers’ Compensation.

Answer 54

True

Question 55

Employer group health plans that have _____ or more enrolled employees are required to provide primary disability coverage for disabled employees who are below the age of _____ and have not retired.

Answer 55

100
65

Question 56

Employer group health plans must provide primary coverage to individuals with ESRD for _____ months, after which Medicare provides primary coverage.

Answer 56

30 months

Question 57

TF: Individuals who remain employed upon reaching the age of 65 can remain insured under their employer’s group coverage and postpone enrollment in Medicare until they reach retirement. Medicare is primary if an individual retains group employer coverage and enrolls in Medicare, and there are fewer than 20 employees insured under the group plan. However, if there are 20 or more employees insured under the employer group coverage, then Medicare is secondary.

Answer 57

True

Question 58

Employer group health plans must provide primary coverage to individuals with ESRD for ___ months, after which Medicare provides primary coverage.
Select one:
a. 5
b. 10
c. 24
d. 30

Answer 58

D

Question 59

All the following statements about Medicare and Medicare supplement are correct, EXCEPT:
Select one:
a. Associations (e.g., fraternal) and groups may not offer supplemental Medicare coverage to their members who are age 65 or over.
b. If individuals work beyond age 65 and remain under their employer’s group health plan, Medicare may be a secondary payer.
c. Medicare supplement insurance is most often purchased from private insurers.
d. Medicare is a secondary payer to employer plans for individuals who have Medicare because of a covered disability.

Answer 59

A

Question 60

Employer group health plans that have 100 or more enrolled employees are required to provide primary disability coverage for disabled employees who are below the age of ____ and have not retired.
Select one:
a. 40
b. 59 1/2
c. 65
d. 75

Answer 60

C

Question 61

Marie, age 65, has group health coverage through work and her employer has 10 employees. If Marie enrolls in Medicare, what is the primary payor?
Select one:
a. Medicare
b. Marie’s employer
c. Both Medicare and Marie’s employer
d. Neither Medicare nor Marie’s employer

Answer 61

A

Question 62

Employer group health plans must provide primary coverage to individuals with end stage renal disease for 30 months, after which Medicare provides ______ coverage.
Select one:
a. Primary
b. Secondary
c. No
d. Tertiary

Answer 62

A