Chapter 4: Social Insurance Flashcards
What is medicare?
A federal medical expense insurance program for people age 65 and older even if the individual continues to work
Will a person who is 67 be eligible to get medicare benefits if they continue to work?
Yes
What two classes of people can receive medicare benefits REGARDLESS OF AGE?
Anyone who has been entitled to Social Security disability income benefits for 2 years or has a permanent kidney failure (End Stage Renal Disease-ESRD).
Martin is 67 years old and moved to Texas from France 7 years ago. Does he qualify for FREE medicare?
No, but he may be able to pay if the following eligibility requirements are met:
-65 years of age or older
-Has not worked enough quarters to have social security coverage
-Are lawfully admitted aliens (green card holders) who have constantly lived in the United States for 5 years or longer and don’t qualify for social security benefits.
What are the four parts of medicare?
- Part A (Hospital Insurance): is financed through a portion of the payroll tax (FICA)
- Part B (Medical Insurance): is financed from monthly premiums paid by insureds and from the general revenues of the federal governement
- Part C (medicare Advantage): allows people to receive all of their health care services through available provider organizations
- Part D (Prescription Drugs): is a prescription drug coverage
Does medicare require a primary care provider to act as a gatekeeper to a specialist?
No as long as the specialist is enrolled in Medicare.
What does Medicare Part A pay for?
Hospital Care
Inpatient Care ina skilled nursing facility
Home health care
Hospice care
How many quarters of work does it take to receive social security retirement benefits?
40 quarters
How much is the standard cost for medicare part A if you have worked for fewer than 30 quarters?
$506
What is the standard cost for medicare part A if you have worked from between 30-39 quarters?
$278
What are the three enrollment periods for Medicare Part A?
Initial enrollment: 3 months prior and after insured’s 65th birthday
General enrollment period: between January 1 and March 31 of each year.
Special enrollment period: At any time during the year if the individual or his/her spouse is still employed and covered under a group health plan.
What does Medicare Part A cover?
Inpatient Hospital Care
Skilled Nursing Facility care
Home Health Care
Hospice Care
How are benefits broken down for medicare part A?
Medicare Part A-Hospital Insurance
1-60 day = 100% after the deductible
61-90= daily copayment but otherwise covered.
How many lifetime reserve hospital care days do medicare patients have?
60 days
What are the copayments like if a person has to tap into their lifetime reserve of 60 days of hospital care?
The copayments are double the copayments paid for the last 30 days of their 90 day hospitalization.
How is blood covered in medicare?
Blood is covered, except for the first 3 pints which is out-of-pocket/
How many days is inpatient mental health care limited to in a psychiatric facility under medicare?
190 days in a lifetime.
How long does a Medicare insured have if released from a hospital for a sickness and has to go back for that same sickness, before a new benefit period starts and they have to pay a new deductible.=?
60 days
How many days does Part A Medicare coverage pay for in a skilled nursing facility care unit?
100 Days BUT it has to. be following 3 days in an inpatient hospital for the related illness.
How many days does medicare limit home health care visits?
No limit
What does Medicare Part B cover?
Pays for doctor’s services and a variety of other medical services and supplies that are not covered by hospital insurance.
Is Part B optional?
Yes
Is Part B free?
No, it comes with a monthly premium, that can be higher if the insured has a higher adjusted gross income
When can you enroll in Part B if you didn’t enroll initially?
The general enrollment period (Jan 1 through March 31)
How much does Part B cover after the deductible is met?
80%
The insured pays 20%
Will Medicare Part B cover someone if they need to see a doctor in another state?
Yes, you can see a doctor anywhere in the US
Does Part B cover home health visits?
Yes but the services are provided on a part-time basis with limits on the number of hours per day and days per week.
Does Medicare Part B cover prescription drugs?
Yes, there is limited coverage. Only medicines that are administered in a hospital outpatient department under certain cirvcumstances, such s injected drugs at the doctor’s office, some oral cancer drugs, nebulizer are covered
Does Medicare Part B cover outpatient treatment of mental illness?
Yes.
True or False: Part B covers yearly wellness visits.
Yes
What does Medicare Advantage (Part C) cover?
Part C plans may have lower out-of-pocket costs than Original Medicare. They may also offer extra coverage, such as vision, hearing, dental, and other health and wellness programs.
Who is eligible for Medicare Advantage?
To be eligible for Medicare Advantage, beneficiaries must also be enrolled in Medicare Parts A and B.
Who provides the care for Medicare Advantage patients?
Medicare Advantage is Medicare provided by an approved Health Maintenance Organization or Preferred Provider Organization.
What are the advantages of using HMO and PPO for Medicare Advantage?
Many HMOs or PPOs do not charge premiums beyond what is paid by Medicare.
The advantages of an HMO or PPO for a Medicare recipient may be that there are
-no claims forms required
-almost any medical problem is covered for a set fee so health care costs can be budgeted
-HMO or PPO may pay for services not usually covered by Medicare or Medicare supplement policies, such as prescriptions, eye exams, hearing aids, or dental care.
Who runs Private Fee-for-Service Plans?
This is a medicare advantage plan offered by private insurance companies.
What plan covers
Is Part D optional?
Yes
How are stand-alone Part D plans paid for?
fee-for-service basis
Does Part D have a premium?
A deductible?
Yes and yes
After the deductible is paid the beneficiary will pay 25% until they reach have reached their out-of-pocket spending limit ($7,400)
What happens in Part D when someone has reached their out-of-pocket limit?
CATASTROPHIC COVERAGE begins automatically which will cover 95% of prescription drug costs.
What is the primary coverage for someone who is 67 and still working?
The employer insurance is the primary coverage and medicare is secondary.
Who issues medicare supplement plans aka Medigap plans?
Private insurance companies and HMOs
What does Medigap cover?
Medicare Supplement policies pay some or all of Medicare’s deductibles and copayments.
What does Omnibus Budget Reconciliation Act of 1990 (OBRA) do?
A law that authorized the NAIC to develop a standardized model for Medicare supplement policies
True or False: Medicare Supplement policies cannot be used to pay for Medicare Advantage (Part C) copayments, deductibles, or premiums.
True
Can someone who is enrolled in Medicaid be issued a Medigap policy?
No.
What core benefit must be found in all policies marketed as Medigap coverage?
The core benefits found in Plan A must be offered in all the plans
What are the core benefits that Medicare Supplement Plan A provides?
-Part A coinsurance/copayment (NOT Part A deductible);
-Part A hospital costs up to an additional 365 days after Medicare benefits are used up;
-Part A hospice care coinsurance/copayment;
-Part B coinsurance/copayment; and
-The first 3 pints of blood (“blood deductible” for Parts A and B).
What does Plan B in Medicare Supplement cover?
Core benefits plus Medicare Part A deductible.
What does Plan D in Medicare Supplement cover?
Core benefits, Medicare Part A deductible, skilled nursing facility coinsurance, and the foreign travel benefit.
What does Plan G in Medicare Supplement cover?
Core benefits, Medicare Part A deductible, skilled nursing facility coinsurance, 100% of Medicare Part B excess charges, and the foreign travel benefit. This plan must pay for services of activities of daily living (ADL) that Medicare doesn’t cover
What does Plan K in Medicare Supplement cover?
Includes 50% of the Medicare Part A deductible and 50% of skilled nursing facility coinsurance.
What does Plan L in Medicare Supplement cover?
Includes 75% of the Medicare Part A deductible and 75% of skilled nursing facility coinsurance.
What does Plan M and N in Medicare Supplement cover?
Provide benefits similar to Plan D, but the co-pays and deductibles might be different.
True or False: All Medigap policies are guaranteed renewable
True
How long is the free look provision for Medigap policies?
30-day free look
What kind of plan is medicare SELECT policies most like?
HMO- in-network providers
Which plan covers the medical care for those whose income and resources are insufficient and is federally and state funded?
Medicaid
What is also referred to as Old Age, Survivors, and Disability Insurance (OASDI)?
Social security benefits
What is the definition of disability under Social Security?
The inability to engage in any gainful work that exists in the national economy. The disability must result from a medically determinable physical or mental impairment that is expected to result in early death, or has lasted or is expected to last for a continuous period of 12 months
How many credits does a person need to qualify for social security benefits?
40 credits
When do benefits arrive once someone is approved to get social security benefits?
5 month waiting period
Payments start on the 6th month
How is the amount of social security benefits calculated?
The person’s Primary Insurance Amount (PIA). The PIA is based on the person’s average indexed earnings on which Social Security taxes have been paid.
Do Social Security benefits end at retirement age?
Yes
How long is survivor benefits for someone with social security benefits?
3 months
