Chapter 5 Review (Health): Private Insurance Flashcards
This insurance is specifically designed for individuals by the age of 65 who have enrolled in Medicare however, anyone currently receiving Medicare Parts A and B is eligible to participate in a _____ policy
Medicare Supplement (Medigap)
A _____ policy is a Medicare supplement insurance policy sold by private insurance companies to cover medical costs not covered by the government in Medicare Parts A and B.
Medigap
Medigap policies do not
pay costs for Medicare Parts C and D
As of _____ _____, there are _____ standardized Medigap plans. Each of the _____ plans has a letter designation of
June 2010,
10
A, B, C, D, F, G, K, L, M, or N
A Medicare Supplement policy must NOT contain benefits which
duplicate Medicare benefits
Individuals over 65 who have just enrolled in Medicare Part B for the first time _____ _____ _____ a Medicare Supplement policy and _____ _____ _____ if they apply for coverage within _____ _____ of Part B enrollment (in other words, Medicare Supplements must be guaranteed issue during open enrollment)
cannot be refused
cannot be rated
6 months
All Medicare supplement policies must be _____ _____ and can only be canceled by the insurer for nonpayment of premiums
guaranteed renewable
Medicare Supplement Plans _____ and _____ are the only Medicare Supplement insurance plans that cover costs known as Medicare Part B excess charges
F and G
An _____ _____ is the difference between what a doctor or provider charges and the amount Medicare will pay
excess charge
o The policy must supplement both Part A and Part B of Medicare
o The policy must automatically adjust its benefits to reflect statutory changes in Medicare
o The policy must cover all expenses not covered by Part A from the 61st to the 90th day. Furthermore, it must cover the lifetime reserve copayment and must provide full coverage for an additional 365 days after Medicare benefits are exhausted.
o If the policy excludes coverage for preexisting conditions, the exclusion cannot exist for longer than six months. That is, no coverage can be denied as a preexisting condition after the policy has been in effect for six months.
o Part B expenses not covered by Medicare (that is, the 20% co-payment) must be covered by the Medigap policy. However, policies may include a deductible before this benefit becomes payable.
o The policy must include a minimum 30 day free-look provision.
six minimum standards applying to all policies designated as Medicare Supplement Insurance.
All Medicare Supplement plans cover coinsurance on hospital costs, up to an additional 365 days after Medicare Part A hospital benefits run out. All Medigap policies also cover at least part of these costs:
- Medicare Part A hospice coinsurance or copayment
- Medicare Part B coinsurance or copayment
- First 3 pints of blood received as a hospital inpatient
With a _____ _____ plan, the insured agrees to use preferred providers, and in exchange, pay a lower premium
Medicare Select
There are a number of _____ _____ _____ that have contracted with the Health Care Financing Administration to provide both Part A and Part B services to Medicare recipients. Medicare _____ _____ _____ are offered by private companies, which can decide each year to join or leave Medicare.
Managed Care Organizations (MCOs)
managed care plans
These plans are Medicare provided by an approved Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Private Fee For Service (PFFS) Plan
Medicare Advantage Plans (Medicare Part C)
Another choice is a _____ _____ _____ _____. In this type of plan 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
In addition to the premium, Medicare Advantage enrollees normally must pay a _____ _____ per visit or per service
small copayment
Medicare Part C does NOT cover
long-term care
LTC refers to care provided for an
extended period of time (normally more than 90 days).
Most LTC policies pay the insured a _____ _____ ______ for each day the policy covers, regardless of what the care costs
fixed dollar amount
An _____ illness is a serious condition, such as pneumonia or influenza, from which the body can fully recover with proper medical attention
acute
Some people will suffer from chronic conditions, such as arthritis, heart disease, or hypertension, which are
treatable but not curable illnesses
Most long-term care insurance policies will pay benefits when you cannot perform at least
two Activities of Daily Living (ADL).
- Personal hygiene - bathing, grooming and oral care
- Dressing - the ability to make appropriate clothing decisions and physically dress oneself
- Eating - the ability to feed oneself though not necessarily to prepare food
- Maintaining continence - both the mental and physical ability to use a restroom
- Transferring - moving oneself from seated to standing and get in and out of bed
These are the
Five basic categories of “The Activities of Daily Living” (ADL)
This is continuous, around-the-clock care provided by licensed medical professionals under the direct supervision of a physician. It is usually administered in nursing homes.
Skilled nursing care
This is provided by registered nurses, licensed practical nurses, and nurse’s aides under the supervision of a physician. It’s provided in nursing homes for stable medical conditions that require daily, but not 24-hour, supervision.
Intermediate nursing care
This kind of care provides assistance in meeting daily living requirements, such as bathing, dressing, getting out of bed, toileting, and so on.
Custodial care
Home health care can include
skilled care and unskilled care.
This form of care is designed to provide a short rest period for a family caregiver.
Respite care
Amounts received under an LTC contract are _____ _____ _____ because they are considered amounts received for personal injuries and sickness
excluded from income
This is a 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 _____ coverage.
The Long-Term Care Partnership Program
Medicaid
The difference between a Long- Term Care Partnership Plan and a Non-Partnership Plan is
asset protection
Which Long Term Care insurance statement true?
Pre-existing conditions must be covered after the coverage has been in force for six months.
(Pre-existing conditions are those for which medical advice or treatment was recommended by or received from a health provider within 6 months preceding the effective date of an individual long-term care policy.)
A reimbursement policy pays what amount of covered long-term care expenses?
Actual covered expenses up to the daily maximum
