Chapter 8: Social Insurance

Question 1

Benefit Period

Answer 1

A period of time during which benefits paid under the policy

Question 2

Enrollee

Answer 2

A person enrolled in a heath insurance plan, an insured [doesn’t include dependents of the insured]

Question 3

Pre-existing conditions

Answer 3

Conditions for which the insured has received diagnosis, advice, care, or treatment during a specific time period prior to the application for health coverage

Question 4

Premium

Answer 4

The money paid to the insurance company for the insurance coverage

Question 5

Social Security disability insured status

Answer 5

Fully insured or currently insured, depending on the number of coverage credits earned

Question 6

Waiting period

Answer 6

A period of time that must pass after a loss occurs before the insurer starts paying policy benefits

Question 7

What is Medicare?

Answer 7

Medicare is a federal medical expense insurance program for people age 65 and older even if the individual continues to work. Medicare benefits are also available to anyone, regardless of age, who has been entitled to social security disability income benefits for two years or has a permanent kidney failure [end stage renal disease-ESRD]

Question 8

What is Medicaid?

Answer 8

A medical benefits program jointly administered by the individual states and the federal government.

Question 9

Who is Medicare administered by?

Answer 9

Medicare is administered by the Center for Medicare and Medicaid Services [CMS], which is a division of the United States department of health and human services.

Question 10

What are the four parts that Medicare is divided into?

Answer 10

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 government;
3. Part C [Medicare advantage] allows people to receive all of their healthcare services through available provider organization;
4. Part D [Prescription drugs] is for prescription drug coverage

Question 11

What parts of Medicare does the term original Medicare referred to and what does it cover and what does it not require?

Answer 11

Original Medicare refers to part A-hospital insurance, and part B-medical insurance only. It covers healthcare from any doctor, healthcare provider, hospital or facility that accepts Medicare patients. It doesn’t usually cover prescription drugs. It does not require the patient to choose a primary care doctor, nor does it require a referral to see a specialist, as long as the specialist is enrolled in Medicare.

Question 12

Actual charge

Answer 12

The amount a physician or supplier actually bills for a particular service or supply.

Question 13

Ambulatory surgical services

Answer 13

Care that is provided at I ambulatory center. These are surgical services performed at a center that do not require a hospital stay unlike in-patient hospital surgery.

Question 14

Approved amount

Answer 14

The amount Medicare determines to be reasonable for a service that is covered under part B of Medicare.

Question 15

Assignment

Answer 15

The physician or a medical supplier agrees to accept the Medicare-approved amount as full payment for the covered services.

Question 16

Carriers

Answer 16

Organizations that process claims that are submitted by doctors and suppliers under Medicare.

Question 17

Coinsurance

Answer 17

The portion of Medicare’s approved amount that the beneficiary is responsible for paying.

Question 18

Comprehensive outpatient rehabilitation facility services

Answer 18

Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.

Question 19

Deductible

Answer 19

The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.

Question 20

Durable medical equipment

Answer 20

Medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home.

Question 21

Excess charge

Answer 21

The difference between the Medicare-approved amount for a service or supply and the actual charge.

Question 22

Intermediaries

Answer 22

Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospice and certain other providers of health services.

Question 23

Limiting charge

Answer 23

The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment.

Question 24

Nonparticipating

Answer 24

Doctors or suppliers who may choose whether or not to accept assignment on each individual claim.

Question 25

Outpatient physical and occupational therapy and speech pathology services

Answer 25

Medically necessary outpatient physical and occupational therapy or speech pathology services prescribed by a doctor or therapist.

Question 26

Pap smear screening

Answer 26

Provides for a Pap smear to screen for cervical cancer once every two years.

Question 27

Partial hospitalization for mental health treatment

Answer 27

A program of outpatient mental health care.

Question 28

Participating doctor or suppliers

Answer 28

Doctors and suppliers who sign agreements to become Medicare-participating. For example, they have agreed in advance to accept assignment on all Medicare claims.

Question 29

Peer review organizations

Answer 29

Groups of practicing doctors and other healthcare professionals who are paid by the government to review the care given to Medicare patients.

Question 30

What does Medicare Part A help to pay for?

Answer 30

Medicare Part A helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.

Question 31

What are the five eligible conditions that individuals qualify for under Medicare Part A?

Answer 31

1. A citizen or a legal resident of the United States age 65 or over and qualified for Social Security or railroad retirement benefits-aged;
2. Is 65 years old or over and entitled to monthly Social Security benefits based upon the spouses work record, and the spouse is at least 62;
3. Is younger than 65, but has been entitled to Social Security disability benefits for 24 months-disabled;
4. Has end-stage renal disease [ESRD]-permanent kidney failure that requires dialysis or a transplant;
5. Has ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease) - automatically qualifies for Part A The month disability benefits begin.

Question 32

What are the three options for those who want to sign up for Medicare Part A?

Answer 32

1. Initial enrollment period: When an individual first becomes eligible for Medicare [starting three months before turning age 65, ending three months after the 65th birthday];
2. General enrollment period: between January 1 and March 31 each year;
3. 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.

Question 33

What can happen if an individual fails to sign up for Medicare when they first become eligible?

Answer 33

Those who are not eligible for premium-free part A can purchase the coverage for a monthly premium. If individuals fail to sign up for part A when they first are eligible, the monthly premium may go up 10% unless the person becomes eligible for a special enrollment period.