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Health Insurance > Chapter 8 > Flashcards

Chapter 8 Flashcards

1
Q

Medicare

A

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

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2
Q

Medicare Part A (hospital)

A

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

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3
Q

Eligibility for Medicare Part A

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

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4
Q

Enrollment Periods for Part A

A

Initial, general, and special

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5
Q

Inpatient hospital care

A

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.

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6
Q

First 20 days in a skilled nursing facility

A

Are covered 100% by Part A, but Part A will help pay for 100 days

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7
Q

Home Health Care

A

For an individual being confined to the home, hospital insurance can pay the full approved cost of home health visits

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8
Q

Part A Exclusions

A

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

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9
Q

Medicare Part B (Medical)

A

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

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10
Q

Part B Eligibility

A

Optional and offered to everyone who enrolls in Part A

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11
Q

Part B Enrollment

A

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

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12
Q

Home Health Visits

A

Will be paid for if recommended by doctor and insured is eligible

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13
Q

Prescription Drugs

A

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

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14
Q

Part B Exclusions

A

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

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15
Q

Medicare Part C (Advantage)

A

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

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16
Q

Part C Eligibility

A

Must be enrolled in Part A and B

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17
Q

Medicare Part D (Prescription Drugs)

A

Optional coverage provided through private prescription drug plans that contract with Medicare

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18
Q

Part D Benefits

A

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

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19
Q

Part D Enrollment

A

If one does not enroll when first eligible they must pay a 1% penalty for every month enrollment is delayed

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20
Q

Integrated Plan

A

Groups coverages together, including HMOs and PPOs

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21
Q

Stand-Alone Plans

A

Fee-for-service

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22
Q

Donut hole

A

When benefit limit is reached, beneficiary is responsible for a portion of costs

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23
Q

Catastrophic coverage

A

When spending reaches limit of coverage gap, 95% is prescription drug costs will be covered

24
Q

Medicare Supplements

A

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

25
Q

Medicare Supplement/Medigap Enrollment

A

Person may not be denied based on health status, claims experience, receipt of health care or medical condition

26
Q

Medicare Supplement/Medigap Open Enrollment

A

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

27
Q

Standard Medicare Supplement Benefit Plans

A

Developed by NAIC; Plans go from A-N

28
Q

Core Benefits of Plan A

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

29
Q

Medicare SELECT

A

Medicare supplement policy that contains restricted network provisions - provisions that condition the whole of partial payment of benefits on the use of network providers

30
Q

Medicare SELECT costs

A

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

31
Q

Twisting

A

High-pressure tactics and misleading advertising

32
Q

Medicare Supplement Policy Exclusions

A

Losses for preexisting conditions incurred more than 6 months from the effective date of coverage cannot be excluded

33
Q

OBRA requirements

A

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

34
Q

Medicaid

A

A federal and state funded program for those whose income and resources we insufficient to meet the cost of necessary medical care

35
Q

Medicaid Eligibility

A

Low income/assets, blindness, disability, pregnancy, age (over 65), caring for children with welfare

36
Q

Medicaid Benefits

A

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

37
Q

Long-Term Care (LTC)

A

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.

38
Q

LTC Coverage

A

Must be provided for 12 consecutive months in a setting other than an acute care unit of a hospital

39
Q

LTC Eligibility

A

Must be unable to perform some of the activities of daily living (ADL)

40
Q

Comprehensive Coverage

A

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

41
Q

Levels of Care

A

Skilled nursing care, intermediate care, and custodial care are covered. Coverage for home health, adult day care, hospice, and respite may be provided

42
Q

Skilled Care

A

Daily nursing and rehabilitative care that can only be provided by medical personnel under the direction of a physician

43
Q

Intermediate Care

A

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

44
Q

Custodial Care

A

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

45
Q

Adult Day Care

A

Care provided for functionally impaired adults on a less than 24 hour basis

46
Q

Residential Care

A

Provided while the insured resides in a retirement community

47
Q

Assisted Living

A

Offers help with nonmedical aspects of daily activities

48
Q

Respite Care

A

A provides relief to family caregiver

49
Q

Benefit periods

A

The longer the benefit period, the higher the premium

50
Q

LTC Exclusions

A

Preexisting conditions and diseases; mental/nervous disorders/diseases; alcohol/drug addiction

51
Q

LTC Partnership

A

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

52
Q

Shopper’s Guide

A

Must be provided by NAIC and presented to the applicant at the time of application

53
Q

Outline of Coverage

A

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

54
Q

LTC Preexisting Conditions

A

LTC will not cover the first 6 months of the contract unless it is replacing another LTC policy

55
Q

Unintentional Lapse

A

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

56
Q

Nonforfeiture Benefit

A

May be a rider; must be offered

57
Q

Violation Penalty

A

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

Health Insurance (5 decks)

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