Insurance10

Question 1

Eligibility for Medicare Coverage

Answer 1

Age 65 and over or
■ Kidney failure (end-stage renal disease) or
■ Received Social Security disability for at least 24 months

Question 2

Medicare Part A

Answer 2

Eligibility
–– Automatic for persons age 65 and eligible for Social Security
–– Supported by payroll taxes
–– Premium charge for those not fully qualified for Social Security
■ Coverages
–– Hospital
■ 90 days per benefit period
■ New benefit period starts 60 days after discharge
■ Additional 60 lifetime days
■ Deductible per benefit period—after deductible Medicare pays 100% of first 60 days
■ Patient pays co-pay per day for days 61-90
■ Patient pays a higher daily co-pay for lifetime reserve days
–– Skilled Nursing Facility (SNF)
■ Medical treatment
■ Following a hospital stay of at least three days
■ 100 days of coverage
–– Days 1–20— 100% paid by Medicare
–– Days 21 – 100—daily co-pay paid by patient
–– Home Health
■ Health care provided in the home
■ Not sitting services
■ 100% paid by Medicare
■ Medicare pays 80% of durable medical equipment in the home
–– Hospice
■ Comfort care for terminally ill and family
■ Can be provided in the home or an approved facility
–– Excluded
■ First three pints of blood
■ Private duty nursing
■ Non-medical services
■ Intermediate care
■ Custodial care

Question 3

Medicare Part B

Answer 3

Monthly premium that increases with income level
■ Not required—can have Part A only
■ Initial enrollment period
–– Three months before age 65
–– Month of age 65
–– Three months after age 65
■ Annual open enrollment period (AEP)
–– January 1 through March 31 each year
–– Coverage effective July 1
■ Coverages
–– Doctor
–– Outpatient services—tests etc.
–– Home health (if not covered by Part A)
■ Calendar year deductible
■ 80/20 coinsurance after deductible
■ No stop loss

Question 4

Medicare Exclusions

Answer 4

Routine physical exams beyond the initial one described previously;
■ Routine foot, vision, dental, or hearing care;
■ Most immunizations;
■ Most outpatient prescription drugs;
■ Physician charges above Medicare’s approved amount;
■ Private-duty nursing;
■ Cosmetic surgery (unless needed to repair an accidental injury);
■ Most care received outside the US; and
■ Expenses incurred as a result of war or act of war.

Question 5

Medicare Part C—Advantage Plans

Answer 5

Medicare contracts with and pays private companies
■ Enrollees medical expenses paid by the private plan
■ Enrollee must be enrolled in Medicare Part A & B
■ Private company may charge the enrollee a fee
■ May provide outpatient drug coverage
■ Four types of Medicare Advantage plans:
–– Medicare managed care plans
■ HMO or POS
■ Gatekeeper
■ Care must be obtained from the plan’s network of providers
■ Enrollees may have to pay a co-payment per doctor visit
– PPO
■ No gate keeper
■ More cost if outside of network
–– Private fee-for-service (PFFS) plans
■ Plan negotiates the fees that providers will be paid.
–– Medicare specialty plans
■ Special needs such as kidney failure

Question 6

Medicare Part D Drug Plan

Answer 6

Purchased from a private company
■ Medicare pays the private company
■ Private company pays the drug store
■ Premium charge—reduced by income level
■ Annual deductible
■ 25% co-pay until gap
■ Payment by policy stops—donut hole
–– Discounts on drug costs in donut hole
■ 5% co-pay after donut hole
■ Gap—donut hole—ends in 2020

Question 7

Group Health/Medicare

Answer 7

Employers with less than 20 employees
–– Medicare is primary
■ Employers with 20 or more employees
–– Group plan is primary for employees
–– Medicare is primary for retirees
■ Medicare eligible individuals under age 65
–– Group plan is primary if a large group plan

Question 8

Medicare Supplement Plans (Medigap

Answer 8

Private insurance plan
■ Premiums not subsidized by Medicare
■ Cannot be sold to an enrollee in a Medicare Advantage plan
■ Core benefit Plan A
–– Must cover hospital co-pays for days 61-90 and lifetime days
–– Adds an additional 365 days of coverage to a benefit period—covered at 100%
–– Covers Medicare Part B coinsurance
–– Must be offered if company sells any Medicare supplement plans
–– Doesn’t cover Part A & B deductibles

Question 9

Medigap Regulations

Answer 9

Must be given an NAIC buyers Guide
■ 30 day free look
■ Guaranteed renewal
■ Guaranteed acceptance if bought within six months of enrollment in Medicare Part B
■ Cold lead advertising not allowed
■ Sales commissions cannot exceed 200% of renewal commissions
■ Renewal commissions must be level in years 2–5
■ Replacement sales commissions cannot be greater than the new policies renewal commission
■ If allowed, preexisting conditions cannot be excluded for more than six months
■ Some states, premiums are community rated

Question 10

Medicaid

Answer 10

Health coverage for the poor
■ Regardless of age
■ A person can be covered by Medicare and Medicaid
■ Funded by state and federal government