Chapter 8 - Social Insurance Flashcards
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 government
Part C (Medicare Advantage) allows people to receive all of their health care services through available provider organizations
Part D (Prescription Drugs) is for prescription drug coverage.
Medicare Assignment
The physician or a medical supplier agrees to accept the Medicare-approved amount as full payment for the covered services
Medicare Limiting Charge
The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignments
What part of Medicare covers hospital outpatient care?
Medicare Part B
Medicare Part A does not cover outpatient hospital care
What is covered under Medicare Part A for what periods?
The first 60 days of hospital stays are fully covered with a single deductible
61-90 days are covered with a daily deductible
After 90 days is not covered
What does Medicare Part C do?
It expands Original Medicare benefits through private health insurance programs
What happens after the initial Medicare Part D benefit limit is reached?
A Prescription Drug Benefit plan will pay 75% of all generic and brand name drug costs
What are all Medicare Supplement Plans required to offer?
All Medicare supplement plans must offer the core benefits available in Plan A
What is Social Security disability benefits also referred to as?
Old Age, Survivors, and Disability Insurance (OASDI)
What three categories of people are eligible for Medicare?
- 65+ years old
- Those eligible for Social Security benefits for two years
- Those with permanent kidney failure (regardless of age)
What two types of plans fill the gaps in Medicare coverage?
- Medicare Supplement Policies
- Medigap
What happens to the premiums for Medicare Part B if enrollment is delayed until after the initial enrollment period?
They increase
What are the enrollment periods for Medicare?
- Initial Enrollment: is the six month period starting three months before your 65th birthday
- General Enrollment: 1/1 - 3/31
- Special Enrollment: eight month period following employment termination, SSDI enrollment
What are five areas excluded from Medicare Parts A or B?
- Long-term care
- Eye exams related to prescribing glasses
- Most dental including dentures
- Cosmetic surgery
- Acupuncture
Etc.
What is required in order to be eligible for Medicare Part C?
Enrollment in Parts A and B
What is Medicare Part C?
Medicare Advantage - adds many of the services of HMOs and PPOs through those organizations.
Region dependent
What is required in order to qualify for Medicare Supplement Policies or Medigap?
Enrollment in Medicare Parts A and B
Is it legal to sell Medicare Supplement Policies or Medigap to someone enrolled in Medicare Part C?
No
They serve the same function
Are Medicare Supplement Policies or Medigap guaranteed renewable?
Yes
How long is the free-look period for Medicare Supplement Policies or Medigap?
30 days
What are the three primary ways to get long-term care coverage (LTC)?
- Individual LTC policy
- Group LTC policy
- As a rider on life insurance
What is the minimum legal coverage period for long-term care?
12 months
What is required for eligibility of long-term care?
Inability to perform two ADLs (activities of daily living.
- Bathing
- Dressing
- Toileting
- Eating
- Transferring
- Continence
Six types of LTC exclusions
- Pre-existing conditions
- Mental and nervous disorders
- Alcoholism and drug addiction
- War related illnesses
- Criminal related
- If covered by Medicare or workers comp
What are the six levels of LTC?
- Skilled care
- Intermediate care
- Custodial care
- Home health care
- Adult day care
- Respite care
How is Part B Medicare funded?
By monthly premiums and from the general revenues of the federal government
An insured with Medicare Part D has reached the initial benefit limit and must now pay a portion of prescription drugs costs. What is the term for this gap in coverage?
The donut hole
How many pints of blood will be paid for by Medicare Supplement core benefits?
First 3 pints
In which Medicare supplemental policies are the core benefits found?
All plans (A-N)
Over and above premiums, what must the patient pay under Medicare Part B?
20% of covered charges above the deductible
To sign up for a Medicare prescription drug plan, individuals must first be enrolled in
Medicare Part A
For how many days of skilled nursing facility care will Medicare pay benefits?
100
Treatment in a skilled nursing facility is covered in full for the first 20 days. From days 21 to 100, the patient must pay the daily copayment. There are no Medicare benefits provided for treatment in a skilled nursing facility beyond 100 days.
For the purposes of obtaining benefits, the Social Security Act defines disability as inability to engage in any gainful employment due to a medically determinable physical or mental impairment that is expected to result in what two factors?
- Death
- Last for a continuous period of 12 months
How long is an open enrollment period for Medicare supplement policies?
6 months
Medicare Part A will pay for up to how many days of inpatient psychiatric hospital care?
190
Are home health and physician and surgeon’s services covered under Medicare Part A?
Home health care is covered
Physician and surgeon’s services are NOT
How long does the initial enrollment period for Medicare Part B last?
7 months
Persons disabled before the age of 24 can qualify for Social Security Benefits with how many work credits over what period of time?
6 work credits earned in the 3 years prior to the start of the disability
