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Insurance Underwriting > Chapter 4: Social Insurance > Flashcards

Chapter 4: Social Insurance Flashcards

1
Q

What is medicare?

A

A federal medical expense insurance program for people age 65 and older even if the individual continues to work

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2
Q

Will a person who is 67 be eligible to get medicare benefits if they continue to work?

A

Yes

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3
Q

What two classes of people can receive medicare benefits REGARDLESS OF AGE?

A

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).

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4
Q

Martin is 67 years old and moved to Texas from France 7 years ago. Does he qualify for FREE medicare?

A

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.

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5
Q

What are the four parts of medicare?

A
  1. Part A (Hospital Insurance): is financed through a portion of the payroll tax (FICA)
  2. Part B (Medical Insurance): is financed from monthly premiums paid by insureds and from the general revenues of the federal governement
  3. Part C (medicare Advantage): allows people to receive all of their health care services through available provider organizations
  4. Part D (Prescription Drugs): is a prescription drug coverage
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6
Q

Does medicare require a primary care provider to act as a gatekeeper to a specialist?

A

No as long as the specialist is enrolled in Medicare.

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7
Q

What does Medicare Part A pay for?

A

Hospital Care
Inpatient Care ina skilled nursing facility
Home health care
Hospice care

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8
Q

How many quarters of work does it take to receive social security retirement benefits?

A

40 quarters

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9
Q

How much is the standard cost for medicare part A if you have worked for fewer than 30 quarters?

A

$506

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10
Q

What is the standard cost for medicare part A if you have worked from between 30-39 quarters?

A

$278

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11
Q

What are the three enrollment periods for Medicare Part A?

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.

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12
Q

What does Medicare Part A cover?

A

Inpatient Hospital Care
Skilled Nursing Facility care
Home Health Care
Hospice Care

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13
Q

How are benefits broken down for medicare part A?

A

Medicare Part A-Hospital Insurance
1-60 day = 100% after the deductible

61-90= daily copayment but otherwise covered.

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14
Q

How many lifetime reserve hospital care days do medicare patients have?

A

60 days

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15
Q

What are the copayments like if a person has to tap into their lifetime reserve of 60 days of hospital care?

A

The copayments are double the copayments paid for the last 30 days of their 90 day hospitalization.

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16
Q

How is blood covered in medicare?

A

Blood is covered, except for the first 3 pints which is out-of-pocket/

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17
Q

How many days is inpatient mental health care limited to in a psychiatric facility under medicare?

A

190 days in a lifetime.

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18
Q

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.=?

A

60 days

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19
Q

How many days does Part A Medicare coverage pay for in a skilled nursing facility care unit?

A

100 Days BUT it has to. be following 3 days in an inpatient hospital for the related illness.

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20
Q

How many days does medicare limit home health care visits?

A

No limit

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21
Q

What does Medicare Part B cover?

A

Pays for doctor’s services and a variety of other medical services and supplies that are not covered by hospital insurance.

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22
Q

Is Part B optional?

A

Yes

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23
Q

Is Part B free?

A

No, it comes with a monthly premium, that can be higher if the insured has a higher adjusted gross income

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24
Q

When can you enroll in Part B if you didn’t enroll initially?

A

The general enrollment period (Jan 1 through March 31)

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25
Q

How much does Part B cover after the deductible is met?

A

80%
The insured pays 20%

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26
Q

Will Medicare Part B cover someone if they need to see a doctor in another state?

A

Yes, you can see a doctor anywhere in the US

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27
Q

Does Part B cover home health visits?

A

Yes but the services are provided on a part-time basis with limits on the number of hours per day and days per week.

28
Q

Does Medicare Part B cover prescription drugs?

A

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

29
Q

Does Medicare Part B cover outpatient treatment of mental illness?

A

Yes.

30
Q

True or False: Part B covers yearly wellness visits.

A

Yes

31
Q

What does Medicare Advantage (Part C) cover?

A

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.

32
Q

Who is eligible for Medicare Advantage?

A

To be eligible for Medicare Advantage, beneficiaries must also be enrolled in Medicare Parts A and B.

33
Q

Who provides the care for Medicare Advantage patients?

A

Medicare Advantage is Medicare provided by an approved Health Maintenance Organization or Preferred Provider Organization.

34
Q

What are the advantages of using HMO and PPO for Medicare Advantage?

A

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.

35
Q

Who runs Private Fee-for-Service Plans?

A

This is a medicare advantage plan offered by private insurance companies.

36
Q

What plan covers

A
36
Q

Is Part D optional?

A

Yes

37
Q

How are stand-alone Part D plans paid for?

A

fee-for-service basis

38
Q

Does Part D have a premium?

A deductible?

A

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)

39
Q

What happens in Part D when someone has reached their out-of-pocket limit?

A

CATASTROPHIC COVERAGE begins automatically which will cover 95% of prescription drug costs.

40
Q

What is the primary coverage for someone who is 67 and still working?

A

The employer insurance is the primary coverage and medicare is secondary.

41
Q

Who issues medicare supplement plans aka Medigap plans?

A

Private insurance companies and HMOs

42
Q

What does Medigap cover?

A

Medicare Supplement policies pay some or all of Medicare’s deductibles and copayments.

43
Q

What does Omnibus Budget Reconciliation Act of 1990 (OBRA) do?

A

A law that authorized the NAIC to develop a standardized model for Medicare supplement policies

44
Q

True or False: Medicare Supplement policies cannot be used to pay for Medicare Advantage (Part C) copayments, deductibles, or premiums.

A

True

45
Q

Can someone who is enrolled in Medicaid be issued a Medigap policy?

A

No.

46
Q

What core benefit must be found in all policies marketed as Medigap coverage?

A

The core benefits found in Plan A must be offered in all the plans

47
Q

What are the core benefits that Medicare Supplement Plan A provides?

A

-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).

48
Q

What does Plan B in Medicare Supplement cover?

A

Core benefits plus Medicare Part A deductible.

49
Q

What does Plan D in Medicare Supplement cover?

A

Core benefits, Medicare Part A deductible, skilled nursing facility coinsurance, and the foreign travel benefit.

50
Q

What does Plan G in Medicare Supplement cover?

A

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

51
Q

What does Plan K in Medicare Supplement cover?

A

Includes 50% of the Medicare Part A deductible and 50% of skilled nursing facility coinsurance.

52
Q

What does Plan L in Medicare Supplement cover?

A

Includes 75% of the Medicare Part A deductible and 75% of skilled nursing facility coinsurance.

53
Q

What does Plan M and N in Medicare Supplement cover?

A

Provide benefits similar to Plan D, but the co-pays and deductibles might be different.

54
Q

True or False: All Medigap policies are guaranteed renewable

A

True

55
Q

How long is the free look provision for Medigap policies?

A

30-day free look

56
Q

What kind of plan is medicare SELECT policies most like?

A

HMO- in-network providers

57
Q

Which plan covers the medical care for those whose income and resources are insufficient and is federally and state funded?

A

Medicaid

58
Q

What is also referred to as Old Age, Survivors, and Disability Insurance (OASDI)?

A

Social security benefits

59
Q

What is the definition of disability under Social Security?

A

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

60
Q

How many credits does a person need to qualify for social security benefits?

A

40 credits

61
Q

When do benefits arrive once someone is approved to get social security benefits?

A

5 month waiting period
Payments start on the 6th month

62
Q

How is the amount of social security benefits calculated?

A

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.

63
Q

Do Social Security benefits end at retirement age?

A

Yes

64
Q

How long is survivor benefits for someone with social security benefits?

A

3 months

Insurance Underwriting (7 decks)

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