Chapter 17: Private Insurance Plans for Seniors Flashcards
Medicare Supplements
Health insurance that provides coverage to fill the gaps in Medicare coverage
Medicare Select
A type of Medicare supplement (medigap) plan sold in some states that can be any medigap plans (A-N) but requires policy holders to receive services within network
Medicare Part D
A program that offers a prescription drug benefit to help pay for drugs they need.
Available for those entitled to Medicare Part A and Part B.
Custodial Care
Must be administered under a physician’s order
Medical care given to meet daily personal needs such as dressing, bathing, getting out of bed.
Home Health Care
Part Time skilled or unskilled cared provided in-home
Adult Day Care
Offered in care centers; a custodial type of care designed for those who require assistance with activities of daily living
Respite Care
A type of health or medical care designed to provide a short rest period for a caregiver.
Temporary.
Core Benefits
All Medicare supplement plans cover coinsurance on hospital costs, up to an additional 365 days after Medicare Part A hospital benefits run out
Long-Term Care Partnership Programs
A federally-supported, state-operated initiative that allows those who purchase a qualified long term care insurance policy to protect a portion of their assets
Continuing Care
Designed to provide a benefit for elderly individuals who live in a continuing care retirement community
Medicare, persons under age 65
Anyone who has received SSDI benefits or railroad benefits for at least 24 months (following 5 month waiting period) because they cannot work before reaching age 65-
Exceptions to the waiting rule:
1. Persons with Amyotrophic lateral sclerosis
2. Persons with end-stage renal disease
Original Medicare
Administered by the federal government and includes;
Medicare Part A
Medicare Part B
Original Medicare Cost-Sharing mechanisms
- Deductible
- Coinsurance
-daily for some hospital services
-20% of medicare approved cost for physician services
Medicare Part D
Seperate drug plan
Medigap
A policy to help pay remaining helaath care costs, copay, coinsurance and deductibles
Medicare Advantage
An all-in-one alternative to the Original Medicare; includes Part A and Part B.
Medicare Part A
1) Monthly premiums are non-existent if worker has 40 quarters (10 years of employment) paid in
2) If not fully insured, based on 0-39 credits ($259) and 0-29 credits ($471).
3) Penalty for not enrolling: Monthly premium of 10% for 2x number of years they delayed.
Part B
-Optional; monthly premium IF elected ($148.50)
- $88K + $176K pay higher premiums
- Penalty: 10% premium penalty per each 12-month period.
2 Conditions when someone 65+ can delay Medicare Part B:
- Covered through a group health insurance plan at work
- Worker’s employer is a qualified COBRA group (20 employees or more)
Medicare Part A
*AKA Hospital Insurance; inpatient hospital care, skilled nursing care, home health care and hospice care
*Federal payroll and self-employment taxes
*Assigns a new benefit period per claim instead of per year
Excludes Physician and Surgeon Charges
Benefit Period of Medicare Part A
Date of one’s admission and ends 60 days after one is discharged from care.
Medicare Part A; Basic Inpatient Benefits
*90 days of inpatient hospital care
*Extra 60 Lifetime Reserve Days (not renewable)
Skilled Nursing Care Benefits
*Qualify following a recent hospitalization of at least 3 inpatient days
*100 days maximum covered
*Coverage can end sooner if healed
*Can only be safely done by professionals
*Does not cover custodial care or provide assistance completing the activities of daily living
Cost Sharing Medicare Part A
*Deductible: $1484
*Co-insurance 61st-90th day: $371
*Daily co-insurance for lifetime reserve days: $742
Medicare Part A Cost:
*Residential Care
*Inpatient Psychiatric
*Home Health
*Hospice Care
*Residential Care- First 20 days, no deductible or coinsurance. 21+ days: $185.50
*In-Patient Psych: Lifetime limit of 190 days
*Home Health:(nursing and pt) covered
*Hospice Care: comfort care, offered with life expectancy for 6 months or less. 2 90 day benefit periods + 6- days increments if appropriate
Medicare Part A Exclusions (5)
- Private duty nurse or attendant in private rooms
- First 3 pints of blood
- Personal conveniences (TV/phones)
- Cost of physicans, surgeons and anesthesiologists
- Services authorized or paid by a government agency
Medicare Part B
AKA Supplemental medical insurance
*Covers doctor’s services, exams, outpatient medical services and supplies, physicians, surgeons and anesthseiologists
*100% of preventative services
Medicare Part B Exclusions (12)
- Private duty nurse
- Custodial care
- Skilled nursing over 100 days
- Vision and hearing
- Dental
- Outpatient prescriptions
- Cosmetic surger
- Routine physical exams and foot care
- Xrays order by chiro
- Acupuncture and massage
- Physican costs exceeding Medicare’s approved amount
- Services authorized or paid by a government agency
Medicare Part B Cost Sharing
*Annual deductible: $203
*Then 80% insurer, 20% insured
*No annual out-of-pocket maximum
Medicare Part C
AKA Medicare Advantage / Medicare + Choice
*Government pays private company a fixed amount per person choosing an advantage plan, usually 95% of the average cost of insuring the individual.
*Must be enrolled in Part A and Part B.
Private Fee For Service Plan (PFFS)
An individual may go to any Medicare-approved doctor or hospital that accepts Medicare payments.
Medicare Advantage Special Needs Plans (SNP)
Provides more focused health care for people with specific disabling chronic conditions in addition to standard health care service, live in a nursing home and are insured under medicare and medicaid
Medicare Part D
AKA Prescription Drug Plan (PDP)
*Optional benefits for 65+ and those with disabilities
Doughnut Hole
$4130 including deductible
[Doughnut Hole Here]
$6550 out of pocket maximum, switches to catastrophic coverage
Enrollment, Medicare Part B
3 months before age 65 and 3 months after age 65
Omnibus Budget Reconciliation Act of 1990
Requires all Medicare supplemental policies to conform to minimum standards.
Medicare Supplement A (PART A & B)
Part A: Hospital Benefits-
1) 100% 61-90 inpatient care
2) 100% life reserve days
Part A: Hopsice Benefits-
1) 100% hospice and coinsurance
Part B: 20% coinsurance amount for approved charges in excess of annual deductibles
Part A & B:
First 3 pints of blood
Plans K & L
*Fully covers Part A daily coinsurance amount.
*Once out of pocket limit is reached, then they cover 100%
Plans F & G
*High deductible, then the policy begins to pay out
*Deductible: $2370
Minimum loss ratio for individual Medigap vs group Medigap
*Individual Medigap: 65%
*Group Medigap: 75%
3 Methos to calculate Medigap Premium Rates
- Issue Age
- Attained Age
- Community Rating
Medicare Select
Works like a closed-end HMO.
Managed care contracts.
Skilled Nursing Care
Consists of daily nursing and rehab care that may be performed by (or under the supervision of) skilled medical personnel and based on an attending physician’s orders. 24 hour a day nursing.
Intermediate Care
Involves intermittent or occasional nursing
Custodial Care
AKA. Non-skilled care
Handling of personal needs such as bathing, walking, eating, dressing or taking medication.
Residential Care Facilities for the Elderly (RCFE)
Non-medical facilities that provide room and board and assistance with ADL’s.
Ideal for people who cant live by themselves but do not need 24 hour care.
Benefit Triggers for LTCI Contracts (2)
- Loss of physical function (2 ADLS)A
- Existence of a cognitive impairment
Activities of Daily Living (ADLs)
- Bathing
- Dressing
- Toileting
- Transferring
- Continence
- Eating
Substantial Assistance
- Hands-on/physical assistance
- Stand-by assistance
LTCI’s benefit periods include:
(5)
2 years
3 years
5 years
10 years
Life
Pool of money concept
Total benefits are limited by available dollars, not number of days.
Automatic Inflation Rider (AIR)
Usually 5% rate
Causing the stated daily benefit to increase and compound annually.
Disclosures required at time of sale of LTCI (4)
- Outline of coverage
- LTCI Buyers/Shoppers Guide
- Personal Worksheet
- Rating Practices
Accelerated Death Benefit Rider
Pays out a portion of the life insurance policy upon the diagnosis of a terminal illness.
Lump sum, but can be monthly.
Qualified vs Non-Qualified
Qualified: cannot discriminate, contributions are deductible from income taxes the year they are maid.
Non-Qualified: discriminate, not tax deductible
Long-Term Care Partnership Program
A federally supported, state-operated initiative that allows individuals who purchase a qualified long-term care coverage to protect a portion of their assets.
Must be tax-qualified and provide inflation protection.
What Medicare Plans cover excess charges from Medicare Part B?
Medicare Supplement Plans F and G are the only Medicare Supplement insurance plans that cover costs known as Medicare Part B excess charges
