chapter 17 Flashcards
health insurance that provides coverage to fill the gaps in Medicare coverage.
medicare supplements
type of Medicare supplement (Medigap) plan sold in some states that can be any of the standardized Medigap plans (A-N) but which requires policy holder to receive services from within a defined network of hospitals and - in some cases - doctors in order to be eligible for full benefits.
medicare select
program that offers a prescription drug benefit to help Medicare beneficiaries pay for the drugs they need. The drug benefit is optional and is available to anyone who is entitled to Medicare Part A or enrolled in Part B. This benefit is available through private prescription drug plans (POPs) or Medicare Advantage (PPO) plans.
medicare part-D
refers to the broad range of medical and personal services for individuals (often the elderly) who need assistance with daily activities for an extended period of time.
long-term care insurance
daily nursing care ordered by a doctor; often medically necessary. It can only be performed by or under the supervision of skilled medical professionals and is available hours a day.
skilled nursing care
level of health or medical care given to meet daily personal needs, such as dressing, bathing, getting out of bed, and soon. Though it does not require medical training, it must be administered under a physician’s order.
custodial care
skilled or unskilled care provided in an individual’s home, usually on a part-time basis
home health care
type of care (usually custodial) designed for individuals who require assistance with various activities of daily living, while their primary caregivers are absent. Offered in care centers.
adult day care
type of health or medical care designed to provide a short rest period for a caregiver. Characterized by its temporary status.
respite care
All Medicare Supplement plans cover coinsurance on hospital costs, up to an additional 365 days after Medicare Part A hospital benefits run out.
core benefits
Federally-supported, state-operated initiative that allows individuals who purchase a qualified long term care insurance policy or coverage to protect a portion of their assets that they would typically need to spend down prior to qualifying for Medicaid coverage.
long term care partnership program
Designed to provide a benefit for elderly individuals who live in a continuing care retirement community.
continuing care
“all in one” alternative to Original Medicare. These “bundled” plans include Part A and Part B.
medicare advantage
those that accept payment directly from Medicare
partipating providers
collect their fees directly from the insured, but may charge up to 15% more.
nonparticipating
prohibits employers from denying benefits to older employees.
The Age Discrimination in Employment Act (ADEA)
cover the expense of a semiprivate room, meals, nursing services, drugs, tests, operating room, and other medical services and supplies. does not include physician or surgeon charges.
Inpatient coverage
begins on the date of one’s admission to a hospital and ends 60 days after one is discharged from care.
benefit period
Each benefit period, Medicare covers up to 90 days of inpatient hospital care, which may be consecutive or sporadic with less than 60-days between each admission. These benefits are restored at the beginning of each benefit period.
Medicare Part A: Basic inpatient benefits
As a backstop to the regular hospital benefits, Part A provides an additional 60 Lifetime Reserve Days. Reserve days are not restored with each new benefit period. We use them once, and they are gone.
Medicare Part A: Reserve inpatient benefits
an individual may go to any Medicare-approved doctor or hospital that accepts Medicare payments. The insurance plan, rather than the Medicare Program, decides how much it will pay and what the Medicare enrollee pays for the services rendered. The plan could include extra benefits that are not covered under the original Medicare plan.
Private Fee For Service (PFFS) Plan
Medicare Advantage specialty plans provide more focused health care for people with specific disabling (chronic) conditions in addition to standard health care services. SNPs are specifically for individuals who are insured under Medicare and Medicaid, live in a nursing home, or suffer from specific chronic conditions (i.e., ESRD).
MEDICARE ADVANTAGE SPECIAL NEEDS PLANS (SNP):
After the first few thousand dollars of coverage, there is a gap in coverage
doughnut hole
It is illegal to sell an individual more than one Medigap policy. The producer must make an effort to determine if other Medigap coverage exists.
duplication of coverage
It is illegal to employ any sales approach that results in a purchase due to an explicit or implicit threat, excessive pressure, or the creation of a climate of fear.
High-pressure tactics
This illegal practice includes any advertising or marketing that does not disclose that an agent might be in contact to solicit the sale of a Medicare supplement contract.
cold lead advertising
As with any other insurance policy, it is illegal to use deception or misrepresentation to induce an individual to replace an existing policy with another contract. The producer must provide an applicant with a notice regarding replacement at the time of application.
twisting
offer intermittent nursing services such as help with managing medications. They provide a number of services such as housekeeping, onsite meal facilities, and social activities.
assisted living facilities
a loss of physical function or the existence of a cognitive impairment.
benefit triggers
the policy’s total benefits are limited by the number of available dollars, not a limited number of days.
“pool of money concept”
provides policy owners with a return of the premiums in certain circumstances, such as a lapse in the policy or death if the insured passes away before using the policy’s benefits.
return of premium rider
a form of inflation protection. It allows the insured to purchase additional coverage at future intervals based on an assumed rate of inflation.
guaranteed insurability rider
the insured has the guarantee of long-term care benefits or, if no care is needed, the guarantee of insurance benefits for themselves or their beneficiaries.
hybrid LTC policy
