Chapter 8: Social Insurance Flashcards
______ is a federal medical expense insurance program for people age 65 and older even if the individual continues to work. ______ benefits are also available to anyone, regardless of age, who has been entitled to Social Security disability income benefits for ______ or has a permanent kidney failure.
- Medicare
- Medicare
- 2 Years
Recent green card holders (permanent residents) or new immigrants may purchase Medicare if they:
- Are age ______ or older.
- Have recently become a U.S. citizen by naturalization and haven’t worked enough quarters to have ______ coverage.
- Are lawfully admitted aliens (green card holders) who have constantly lived in the U.S. for ______ or longer.
- 65
- Social Security
- 5 Years
Medicare is administered by ______, which is a division of the United States Department of Health and Human Services.
The Center for Medicare and Medicaid Services (CMS)
Medicare is divided into 4 parts:
- ______ (______) is financed through a portion of the payroll tax (FICA).
- ______ (______) is financed from monthly premiums paid by insureds and from the general revenues of the federal government.
- ______ (______) allows people to receive all of their health care services through available provider organizations.
- ______ (______) is for prescription drug coverage.
- Part A (Hospital Insurance)
- Part B (Medical Insurance)
- Part C (Medicare Advantage)
- Part D (Prescription Drugs)
The term ______ refers to Part A - Hospital Insurance, and Part B - Medical Insurance only. It covers health care from any doctor, health care provider, hospital or facility that accepts Medicate patients.
Original Medicare
______ refers to when the physician or medical supplier agrees to accept the Medicare-approved amounts as full payment for the covered services.
Assignment
______ helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.
Medicare Part A
An individual is eligible for ______ (______), if he or she qualifies for one of the following conditions:
- A citizen or legal resident of the U.S. age 65 or over and qualified for Social Security or Railroad retirement benefits.
- Is 65 years old or over and entitled to monthly Social Security benefits based upon the spouse’s work record, and the spouse is at least 62.
- Is younger than 65, but has been entitled to Social Security disability benefits for 24 months.
- Has End Stage Rental Disease (ESRD).
- Has ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease).
Medicare Part A (Hospital Coverage)
Monthly Part A premiums are required when a beneficiary is not “______” under Social Security, meaning they have not earned ______ of coverage, and therefore, are not entitled to receive Social Security retirement, premium-free Medicare Part A, and survivor benefits.
- Fully Insured
2. 40 Quarters
Those want to sign up for Medicare Part A have the following three options:
- ______ period: when an individual first becomes eligible for Medicare (starting 3 months before turning age 65, ending 3 months after the 65th birthday).
- ______ period: between Jan 1st and Mar 31st each year.
- ______ period: at any time during the year if the individual or his/her spouse is still employed and covered under a group health plan.
- Initial Enrollment
- General Enrollment
- Special Enrollment
Under Medicare Part A, ______ helps pay for up to 90 days in a participating hospital in any benefit period, subject to a deductible. The first 60 days are covered at ______ of approved charges after the deductible is met. The next 30 days are paid, but they are paid with a daily ______.
- Inpatient Hospital Care
- 100%
- Copayment
Medicare Part A helps pay for up to ______ in a participating skilled nursing facility in each benefit period, following a 3-day inpatient hospital stay for a related illness.
100 Days
For an individual confined to the home and meeting certain other conditions, Medicare Part A hospital insurance can pay the full approved cost of ______ from a participating home health agency.
Home Health Visits
Under certain conditions, Medicare Part A hospital insurance can help pay for ______ for terminally ill insureds, if the care is provided by a Medicare-certified ______.
- Hospice Care
2. Hospice
______ pays for doctor’s services a variety of other medical services and supplies that are not covered by hospital insurance.
Medicare Part B
Medicare ______ is optional and offered to everyone who enrolls in ______. Most people enrolled in Medicare ______ pay the standard monthly premium; however, if an insured’s modified adjusted gross income is above a certain amount, the insured may be required to pay a higher premium.
- Part B
- Part A
- Part B
After the annual medical insurance deductible is met, medical insurance will generally pay for ______ of the approved charges for covered expenses for the remainder of the year. There is no maximum ______ on the ______ coinsurance payable for ______ expenses.
- 80%
- 20%
- Part B
______ plans must cover all of the services covered under the Original Medicare except hospice care and some care in qualifying clinical research studies. These plans may have lower out-of-pocket costs than Original Medicare and may offer extra coverage, such as vision, hearing, dental, and other health and wellness programs.
Medical Advantage (Part C)
To be eligible for ______, beneficiaries must also be enrolled in Medicare Parts A and B.
Medical Advantage (Part C)
______ is Medicare provided by an approved HMO or PPO, many of which do not charge premiums beyond what is paid by Medicare.
Medical Advantage (Part C)
A Medicare ______ is a Medicare Advantage Plan offered by a private insurance company. Medicare pays a set amount of money every month to the private insurance company to provide health care coverage and the insurance company decides how much enrollees pay for the services they get.
Private Fee-For-Service Plan
Another section of Medicare Advantage Plan (Part C), ______, provides more focused and specialized health care for specific groups of people. This includes people who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.
Special Needs Plans
The ______ (______) is an optional coverage provided through private prescription drug plans (PDPs) that contract with Medicare.
Medicare Part D (Prescription Drug)
If Medicare beneficiaries don’t enroll in ______ when they are first eligible, they must pay a(n) ______ for each month they delayed enrollment.
- Part D
2. 1% Penalty
Medicare beneficiaries may choose between ______ plans that offer coverage on a fee-for-service basis, or ______ plans that group coverages together, including PPOs and HMOs (known as Medicare Advantage).
- Stand-Alone
2. Integrated
Those who sign up for the standard ______ plan will have a monthly premium (varies by plan) and a deductible. After the deductible is paid, the plan would provide prescription drug costs coverage until a benefit limit is reached.
Prescription Drug Benefit
Most Medicare drug plans have a(n) ______, also called a “donut hole”. The ______ begins after the beneficiary and the drug plan have spent a certain amount for covered drugs. In the ______, the beneficiary is responsible for 25% of brand name prescription drug costs, and 25% of the plan’s cost for covered generic drugs.
Coverage Gap
