IX. Insurance for Senior Citizens and Special Needs Individuals Flashcards
To whom is Medicare available?
People 65 or older even if they continue to work
What does Medicare Part A cover
Inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care
What is the initial enrollment period for Medicare Part A?
3 months before turning age 65 to 3 months after the month of birth.
How is Part B of Medicare Funded?
monthly premiums and general revenues of the federal government
Who is eligible for Part B of Medicare?
Part B is optional and offered to everyone who enrolls in Part A
When is the general enrollment period for Medicare Part B?
January 1 to March 31st of every year
What is excluded from coverage under Medicare Part B?
Private nursing
Skilled nursing home care cost over 100 days per benefit period
Intermediate nursing home care
What are the advantages of an HMO or PPO for a Medicare recipient?
no claims forms required,
almost any medical problem is covered for a set fee so health care costs can be budgeted,
HMO or PPO may pay for services not usually covered by Medicare or Medicare supplement policies such as prescriptions, eye exams, hearing aids, or dental care.
Who provides primary coverage if an individual who is eligible for medicare is still active under an employer plan?
Employer plan is primary.
What is the purpose of Medicare Supplement Plans?
‘Medigap’ policies are issued by private insurance companies that are designed to fill in some of the gaps in medicare.
Which Medicare supplement plan must be offered in all plans?
Part A. Part B and C are optional.
What is the difference between Medicare SELECT and other Medicare policies?
Usually a lower premium with restricted network provisions.
What must be included on the first page of a replacement policy?
“Notice to the Buyer: This policy may not cover all of your medical expenses”
How long is the free-look period for Medicare Supplement Policies?
30 days
What must be included in the renewal or continuation provision of a Medicare supplement policies?
Any reservation by the insurance company of the right to change premiums, and any automatic renewal premium increases based on the age of the policy holder.
What is the maximum allowed first year commission for the sale of a Medicare Supplement Policy?
200% of the renewal commission.
Describe the purpose for permitted compensation arrangements?
Permitted compensation arrangement detail the circumstances of the compensation made to agents for the sale of Medicare Supplement Policies. Agents may not receive compensation greater than the renewal compensation payable by the replacing insurance company unless the new policy are clearly and substantially greater than in policy being replaced.
What is the purpose of Medicaid?
Federal and State funded program for those whose income and resources are insufficient to meet the cost of necessary medical care.
What is included under the definition of Activities of Daily Living?
ADLs include mobility or transferring, bathing, dressing, toileting, continence, and eating.
Where is skilled nursing care generally provided?
Institutional setting
Describe an individual who would be a candidate for custodial care. who would provide it?
Custodial care is provided for meeting personal needs, and must be given under a doctor’s orders.
Who would be eligible for adult day care? What services would be provided?
provided for functionally impaired adults on less than a 24-hour basis. Care includes transportation to and from the day care center, and a variety of health, social and related activities. Meals are usually included as part of the service.
Regarding Medicare Supplement Plans, What is required of insurance companies during the open enrollment period for an eligible person?
Sell the patient a Medicare supplement plan (Coverage is offered on a guaranteed issue basis)
Cover all pre-existing conditions incurred more than 6 months from the effective date of the coverage
Not charge more for a supplement policy because of past or present health problems.
The Omnibus Budget Reconciliation Act of 1990 requires the employer health plan to provide primary coverage for individuals with end-stage renal (kidney) disease before Medicare becomes primary for how many months?
The Omnibus Budget Reconciliation Act of 1990 as amended by the Balanced Budget Act of 1997 requires the employer health plan to provide primary coverage for 30 months for individuals with end-stage renal (kidney) disease before Medicare becomes primary.
