Chapter 31 - Medicare And Medicaid

Question 1

Medicare (Title 18)
Medicaid (Title 19)

Answer 1

Medicare- 65 and older or CKD (chronic kidney disease), widow or widower over age 50, and those who received Social Security Disability Benefits for 29 months - regardless of age.

Social Security Administration handles the enrollments into Medicare and CMS handles the money and claims processing and writes the rules.

Initial Enrollment Period - 7 month period around your 65 birthday. Enrollment begins 3 months before your birthday month and ends 3 months after your birthday month. There is an annual enrollment period each year, January - March, and coverage starts in July.

Part A - hospital insurance - automatic - no charge/premium - funded by 3% FICA tax
-this also includes home health, skilled nursing services and hospice care.
-pays for up to 90 days of in-patient hospital services, after 90 days the coverage benefits reduce a lot. The 90 days resets if the patient has been out of the hospital for 60 days.
-recipients pay about a $1000 deductible for the first 60 days ($16 per day), they pay 25% of the $1000 for 61-90 days (about $7,500), for 91-150, 50% of the $1000 ( about $30,000).

Part B - doctors and outpatient - optional - costs extra - premium is paid to the federal government
- premium is based on income ranging 140-320 a month.
-covers physician fees, outpatient services such as diagnostic tests, physical therapy, medical equipment, ect.
- does not cover vaccinations, dental, hearing or vision.
- part B recipients are responsible for co-pays.
- monthly costs of Part B (roughly $100-$300) varies with the recipients income level and is automatically deducted by their monthly Social Security check.

Part C - Medicare Advantage - optional -costs extra
- A PPO of HMO plan run by private companies and do no allow a Medicare supplement or Medigap plan.
- MA plans receive funds from both Medicare and the insured.

Pat D - drugs - optional - costs extra
- must be enrolled in part A and B.
- pay a monthly premium to a private company that works with Medicare to provide prescription drugs coverage. This can be rolled into a MA plan.

Coverings Medicare GAPS
- help cover gaps in parts A, B, D. Help cover deductibles, coinsurance, and co pays. From a private company such as a MA or Medigap policy.

Marketing and Selling Rules
- When selling a Medigap or MA plan, the plan must add something or fill in a gap with the plan, not just duplicate the Medicare coverage. The agent must provide notice that they are choosing a replacement plan to their Medicare policy. Must provide a shoppers/buyers guide for the program that outlines coverage. The plan has to be at least guaranteed renewable. They have a 30 day free look period.

Medicaid
- coverage for the poor and have full coverage. Run by the state. No co pays, no deductibles, no cost. In some states even dental and vision is covered.