Chapter 8 Flashcards
Medicare
A federal medical expense insurance program for people age 65 and over, employed or not. Also for anyone who has been entitled to Social Security disability income benefits for 2 years or has ESRD
Medicare Part A (hospital)
Financed through a portion of payroll tax (FICA); Pays for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice
Eligibility for Medicare Part A
Citizen or legal resident of U.S. age 65+ and qualified for SS or Railroad retirement benefits; 65+ and entitled to monthly SS benefits based upon spouse’s work record, and spouse is at least 62; younger than 65 but has been entitled to SS disability benefits for 24 months; has ALS or ESRD
Enrollment Periods for Part A
Initial, general, and special
Inpatient hospital care
Pays for 90 days in hospital, possible deductible. First 60 days are covered 100% after deductible is met. They next 30 are paid but subject to copayment.
First 20 days in a skilled nursing facility
Are covered 100% by Part A, but Part A will help pay for 100 days
Home Health Care
For an individual being confined to the home, hospital insurance can pay the full approved cost of home health visits
Part A Exclusions
dental care/dentures; cosmetic surgery; custodial care, unless skilled nursing care is provided at the same time; health care outside of US; hearing aids and exams; most prescription drugs; routine eye care; immunizations; first 3 pints of blood
Medicare Part B (Medical)
Financed from monthly premiums paid by insured’s and from general revenues of the federal government; pays for doctor’s services and other medical services/supplies not covered in Part A
Part B Eligibility
Optional and offered to everyone who enrolls in Part A
Part B Enrollment
You are offered Part B after becoming eligible for Part A. If you decline, you must wait until the next general enrollment (January 1-March 31) to enroll
Home Health Visits
Will be paid for if recommended by doctor and insured is eligible
Prescription Drugs
Only covers medicine administered in a hospital outpatient department such as injected drugs at doctor’s office, some oral cancer drugs, or drugs that require durable medical equipment
Part B Exclusions
Private duty nursing, skilled nursing home care costs over 100 days per benefit period, charges above Medicare approved amount, most outpatient prescription drugs, care received outside of US, custodial care received in home, dental care (except accidental), eyeglasses, hearing aids
Medicare Part C (Advantage)
Allows people to receive all of their health care services through available provider organizations; Must cover all services covered under Original Medicare (Part A and B) except hospice; provided by HMO’s or PPO’s
Part C Eligibility
Must be enrolled in Part A and B
Medicare Part D (Prescription Drugs)
Optional coverage provided through private prescription drug plans that contract with Medicare
Part D Benefits
To be received, coverage must be offered by plan in the area and individual must be enrolled in Part A or Parts A and B
Part D Enrollment
If one does not enroll when first eligible they must pay a 1% penalty for every month enrollment is delayed
Integrated Plan
Groups coverages together, including HMOs and PPOs
Stand-Alone Plans
Fee-for-service
Donut hole
When benefit limit is reached, beneficiary is responsible for a portion of costs
Catastrophic coverage
When spending reaches limit of coverage gap, 95% is prescription drug costs will be covered
Medicare Supplements
Supplement plans known as Medigap are policies issued by private insurance companies to fill the gaps of Medicare; pays some or all of Medicare’s deductibles and copayments; sold and services by private insurers and HMOs
Medicare Supplement/Medigap Enrollment
Person may not be denied based on health status, claims experience, receipt of health care or medical condition
Medicare Supplement/Medigap Open Enrollment
6 month period that guarantees applicant’s right to buy Medigap upon signing up for Part B of Medicare. Must have Part A and B
Standard Medicare Supplement Benefit Plans
Developed by NAIC; Plans go from A-N
Core Benefits of Plan A
Must be found in all plans; Part A coinsurance/copayment, hospital costs, hospice coinsurance/copayment, Part B coinsurance/copayment, first 3 pints of blood
Medicare SELECT
Medicare supplement policy that contains restricted network provisions - provisions that condition the whole of partial payment of benefits on the use of network providers
Medicare SELECT costs
Negotiate with a provider network of doctors, hospitals and specialists to charge lower rates for medical services so costs are kept down for the plan provider and members pay lower premium
Twisting
High-pressure tactics and misleading advertising
Medicare Supplement Policy Exclusions
Losses for preexisting conditions incurred more than 6 months from the effective date of coverage cannot be excluded
OBRA requirements
Large group health plans (100 employees or more) provide primary coverage for disabled individuals under 65 who are not retired; employer health plan provides primary coverage for individuals with ESRD for 30 months; If an employee is insured on a group plan of less than 20 employees, Medicare is primary coverage. Vice versa for groups of 20 or more
Medicaid
A federal and state funded program for those whose income and resources we insufficient to meet the cost of necessary medical care
Medicaid Eligibility
Low income/assets, blindness, disability, pregnancy, age (over 65), caring for children with welfare
Medicaid Benefits
Physician’s services, inpatient/outpatient hospital care, skilled nursing home services, lab and x-Ray services, home health care, family planning, prescription drugs, dental, eyeglasses, private duty nursing, check ups, and medical equipment/supplies
Long-Term Care (LTC)
Individual or group policies or riders that provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or in a nursing home.
LTC Coverage
Must be provided for 12 consecutive months in a setting other than an acute care unit of a hospital
LTC Eligibility
Must be unable to perform some of the activities of daily living (ADL)
Comprehensive Coverage
Covers all care and services, except for those specifically excluded in the following settings: the insured’s home (skilled nursing care, occupational, physical, and rehab therapy), adult day health care centers, hospice, respite, assisted living facilities, Alzheimer’s special care facilities, and nursing homes
Levels of Care
Skilled nursing care, intermediate care, and custodial care are covered. Coverage for home health, adult day care, hospice, and respite may be provided
Skilled Care
Daily nursing and rehabilitative care that can only be provided by medical personnel under the direction of a physician
Intermediate Care
Occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis; ordered by a physician, fulfilled by skilled medical personnel
Custodial Care
Care for meeting personal needs such as assistance with eating, dressing, or bathing and can be provided by nonmedical personnel in an institutional setting or the patient’s home
Adult Day Care
Care provided for functionally impaired adults on a less than 24 hour basis
Residential Care
Provided while the insured resides in a retirement community
Assisted Living
Offers help with nonmedical aspects of daily activities
Respite Care
A provides relief to family caregiver
Benefit periods
The longer the benefit period, the higher the premium
LTC Exclusions
Preexisting conditions and diseases; mental/nervous disorders/diseases; alcohol/drug addiction
LTC Partnership
Allows those who have used some of their private LTC benefits to apply for Medicaid coverage without having to meet the same means/testing requirements
Shopper’s Guide
Must be provided by NAIC and presented to the applicant at the time of application
Outline of Coverage
Must include information about the insurance company, policy number, and important features of the policy: separate document that must be delivered prior to application/enrollment form
LTC Preexisting Conditions
LTC will not cover the first 6 months of the contract unless it is replacing another LTC policy
Unintentional Lapse
Policy may not lapse due to unpaid premium unless 30 days’ notice is given and a reinstatement of coverage provision should be included in the policy
Nonforfeiture Benefit
May be a rider; must be offered
Violation Penalty
If the requirements relating to the regulations of LTC insurance are violated or the marketing of LTC, a civil penalty of up to 3 times then amount of commissions or $10,000 is issued, whichever is greater
