Health Insurance - Ins. for Senior Citizens Flashcards
Medicare
A federal health insurance program designed specifically for people age 65 and over and for certain disabled people. Medicare is funded by payroll taxes. It extends the Social Security program beyond retirement, disability, and survivor benefits into the field of medical expense benefits. Coverage provided under Medicare is divided into four parts: A through D.
Medicare Part A (Hospital Insurance)
Covers institutional medical care, including inpatient hospital care, skilled nursing home care, post-hospital home health care, and hospice care. A special premium is required for coverage between age 65 and full retirement age. No premium is due once full retirement age is met.
Medicare Part B (Medical Insurance)
Covers physicians’ services, outpatient hospital care, physical therapy, ambulance trips, medical equipment, and some preventive services. Part B provides supplemental coverage to Part A. Optional. Requires a premium payment. Those with Part C cannot also have Part B since Part C includes Parts A and B.
Medicare Part C (“Medicare Advantage”)
Is a managed care plan alternative to original Medicare. Provided through commercial insurance companies, this all-encompassing plan combines the coverage of Parts A and B in managed care format similar to a PPO. Optional. Requires a premium payment.
Medicare Part D
Provided through Medicare-approved commercial insurers, Part D adds prescription drug coverage to Medicare Parts A and B. Available to anyone covered under Parts A and B. Optional. Requires a premium payment.
Medicare Eligibility
Available to U.S. citizens and certain permanent residents who
- Are age 65 and older; or
- Have been receiving Social Security disability checks for at least two years; or
- Have end-stage renal disease (ESRD, which is kidney disease requiring a transplant or dialysis); or
- Have Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig’s disease).
Medicare Enrollment
Application for Social Security retirement benefits at age 65 automatically triggers enrollment into Parts A and B. One must opt out of Part B to decline coverage. Alternative, they can opt into Part C. If a person wants to enroll in Medicare but not receive SS retirement benefits until later, there is a separate enrollment process.
Medicare Initial Enrollment Period
A seven-month period including the month in which the recipient turns 65 in which enrollment into Medicare is permitted.
Medicare General Enrollment Period
Qualified individuals who did not sign up for Part A or Part B during the IEP when they were first eligible can sign up during a general enrollment period (GEP) between January 1 and March 31 each year. Coverage will begin July 1. It may be necessary to pay a higher premium for late enrollment.
Medicare Annual Election Period (Open Enrollment Period)
Period of time when qualified individuals may make changes to their Medicare Advantage plans, switch from a traditional Medicare plan to a Medicare Advantage plan, or change Part D prescription drug plans. Runs from October 15 through December 7; new coverage becomes effective the following January 1.
Medicare Disenrollment Period
Individuals who wish to switch from a Medicare Advantage plan to Original Medicare may do so during a special disenrollment period that runs from January 1 through February 14 each year.
Medicare Special Enrollment Period
Individuals who are working and covered under their employer medical plan may defer coverage of Medicare Part B until they actually retire. For these individuals a special enrollment period (SEP) allows them to sign up for Part B after their IEP without penalty. The SEP is available any time during the eight-month period that begins the month after the employment or the group health plan coverage ends, whichever happens first.
Medicare Part A Benefit Period
Medicare Part A covers eligible hospital costs for up to 90 days in any single benefit period. A benefit period ends 60 days after release from the hospital. Medicare recipients also have an additional one-time 60-day reserve.
Medicare Part A Hospital Deductibles and Coinsurance
- Days 1-60: All eligible hospital costs are covered after the Medicare beneficiary pays a deductible ($1,260 in 2015).
- Days 61-90: Recipient pays a daily coinsurance ($315 in 2015), and Medicare pays the daily balance.
- 60-day lifetime reserve: Recipient pays a daily coinsurance ($630 in 2015), and Medicare pays the daily balance.
Skilled Nursing Care
Nursing care normally in a facility that is provided under the supervision of skilled professionals and under a doctor’s orders.
Medicare Part A Skilled Nursing Facility Deductibles and Coinsurance
Medicare Part A pays the full cost for care in a skilled nursing facility for the first 20 days of such care. Skilled nursing care continues to be covered beyond the first 20 days up to 100 days with a daily patient coinsurance of $157.50 (2015).
For care in a skilled nursing facility to be considered “necessary” and thereby covered by Medicare, it must meet certain criteria. For one, the care must be preceded by a hospital stay for the same or related condition and admission to the skilled nursing facility must be within 30 days of the time the patient leaves the hospital. Second, the stay in the skilled nursing facility must be at least three days long.
Medicare Part A Home Health Care Coverage
Covered services include:
- Part-time or intermittent skilled care
- Home health aide services
- Durable medical equipment and supplies
- Certain other services
No prior hospitalization is required for these services to be covered, nor is there a maximum number of allowable home health care visits. Medicare Part A pays 100 percent of the approved amount for services. It also pays 80 percent of the approved amount for durable medical equipment, such as wheelchairs.
Medicare Part A Hospice Care Benefits
The benefit period for hospice care consists of two 90-day periods and an unlimited number of 60-day extensions of benefits. The hospice benefit can be extended beyond the 240-day limit if the beneficiary is recertified as terminally ill.
The hospice benefit has no deductibles. Medicare pays reasonable costs of providing hospice care.
Hospice Care
In-home care for terminally ill individuals.