Competency 14 Section 1 Flashcards
- Custodial care is covered by Medicare
False. Medicare does not cover custodial care or long-term care, which is a common misunderstanding by many beneficiaries. (LO 14-1-2)
- Custodial care (personal care):
a. Assists a person who has a limited ability to conduct his or her routine daily activities because of deficiencies in physical and/or cognitive functions.
b. Typically, custodial care services assist someone with his or her activities of daily living (ADLs) or instrumental activities of daily living (IADLs). – Like LTC
c. Who provides custodial care services:
(1) Unlicensed professionals can provide custodial care.
(2) Family members often provide custodial care in the home.
(3) Aides, volunteers, etc.
(4) A person can provide custodial care to him or herself.
(a) For example, diabetes monitoring
d. Custodial care is not typically covered by Medicare.
- Due to the Affordable Care Act, many states may expand their Medicaid programs in 2014.
True. Due to the Supreme Court Ruling on the Affordable Care Act, not all states must expand their Medicaid programs, but the ones that do will receive additional federal funding to do so. (LO 14-1-2)
- Clients that are enrolled in an employer-sponsored healthcare plan, but are eligible for Medicare, need to clarify which plan will be a “secondary payer” to be sure to avoid out-of-pocket costs
True. (LO 14-1-2)
Primary payer
a. When an individual reaches age 65, under law, Medicare generally becomes the primary payer.
b. The main exception is for an individual or their spouse who is still working, is covered under the employer’s health insurance plan, and whose employer has 20 or more employees.
c. The primary payer is the insurance plan that pays first—up to the limits of the policy.
d. The secondary payer is the insurance plan that pays only if there is a cost not covered by the primary payer.
e. If Medicare is the primary payer
(1) Failing to enroll in Part B means only having coverage in a secondary payer plan—and some secondary plans pay nothing if there is no primary plan coverage.
(2) This can be a trap for the individual who works for a small employer past age 65 or has retiree or COBRA coverage from a former employer who assumes that they have adequate coverage.
(3) The bottom line is that if Medicare is considered by law to be the primary payer, the individual must enroll in Medicare Parts A and B to have adequate insurance coverage
- Care that is provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is the patient’s caregiver can rest or take some time off is considered “hospice care.”
False. This type of care is considered “respite care.” (LO 14-1-2)
(4) Medicare can cover up to 5 days of continuous respite care.
(a) Available if the primary caregiver needs a rest
(b) Respite care can be obtained more than once and again covered by Medicare.
Part A (hospital insurance)
a. Part A of Medicare covers inpatient hospital care including:
(1) Semi-private rooms, meals, general nursing
(2) Drugs and other hospital services and supplies
b. It also includes care at a skilled nursing facility
(1) To qualify, the skilled nursing stay must follow a three-day, medically necessary, inpatient hospital stay for a related illness or injury.
(2) Another requirement is that a doctor must certify that the patient needs daily skilled care.
c. Medicare covers a limited amount of home care—requirements include:
(1) Medically necessary part-time services that include skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy
(2) Ordered by the doctor
(3) Provided by a Medicare-certified home health agency
(4) Patient must qualify as homebound.
d. Hospice care is also covered.
(1) It requires a certification of a terminal illness.
(2) Hospice care covers all items and services needed for pain relief and symptom management as well as medical, nursing, social services, and drugs as well as services Medicare usually does not cover, such as spiritual and grief counseling.
e. Inpatient psychiatric care is also covered, but it has special rules.
(1) Care in a freestanding psychiatric hospital is limited to 190 days in a lifetime
- Starting in 2014, exchanges may be an alternate source of coverage for an early retiree that is not yet eligible for Medicare.
True. Exchanges are established by the Affordable Care Act and will be operational starting in 2014. (LO 14-1-3)
- The Affordable Care Act has a tremendous impact on healthcare coverage and may impact which coverage options are available for retirees in the future.
True. (LO 14-1-3)
- The “Play or Pay” tax of the Affordable Care Act has a significant impact on whether employers will offer healthcare coverage in the future
True. (LO 14-1-3)
- An employer will be subject to the “Play or Pay” Tax in 2014 if they have 25 full-time equivalent employees
False. Employers will only be subject to the “Play or Pay” tax if they employ 50 or more full-time equivalent employees. (LO 14-1-3)
- Comparison shopping using a set of comprehensive factors will help you find the plan that best fits your clients’ needs.
True. (LO 14-1-4)
- Jennie is enrolled in Medicare Part A. She suffers a stroke and is admitted to an inpatient hospital for care, which initiates a benefit period. She is in the hospital for twenty-five days and then is released. How many more days of coverage does she have in the benefit period (not counting life-time reserve days)? (LO 14-1-2) A. 35 days B. 60 days C. 65 days D. 90 days
- The answer is C. Medicare covers 90 days in a hospital in a benefit period. Jennie has 65 days remaining (90 -25).
Medicare Part A benefit periods
a. The amount of coverage provided for hospital care is based on benefit periods.
b. There is a certain amount of coverage per benefit period, and benefits renew if a new benefit period begins.
c. A benefit period begins with first day of inpatient hospital stay and ends after the patient has not received inpatient care in a hospital or skilled nursing facility for 60 days.
d. If a new benefit period begins, this triggers a new deductible payment.
e. For each benefit period, there is a total of 90 days of hospital coverage.
f. In addition, Medicare provides an additional 60 days—referred to as lifetime reserve days—that can only be used once.
- The Affordable Care Act has had an impact on employee health care in which of the following ways? (LO 14-1-4)
I. Those that continue to work after becoming eligible for Medicare may choose to switch to Medicare as the employees’ portion of the cost for employer provided benefits may have increased significantly.
II. Employees receiving employer provided coverage have already seen some increases in benefits including the elimination of lifetime maximum benefits on essential benefits.
A. I only
B. II only
C. Both I and II
D. Neither I nor II
- The answer is C. Both statements are correct
- All of the following are payment elements of the Medicare cost-sharing structure EXCEPT (LO 14-1-1)
A. Premiums
B. Copayments
C. Out-of-pocket limits
D. Coinsurance
- The answer is C. Unlike somehttps://bbcontent.theamericancollege.edu/Course/BbC/01_HS/355/v1/HS355_Outline.pdf other types of medical insurance, there are no limits on the amount of out-of-pocket expenses with Medicare.
