Learning Objective 4 Flashcards
Workers in the US who are NOT covered by Social Security [Card 180]
Acronym - smoked 25L’S while riding the RELIGIOUS RAILROAD in 1984
25% of STATE and LOCAL government workers
RELIGIOUS people who object to govt benefits
RAILROAD employees who have a similar program
Federal employees hired before 1984
Requirements for insured statuses under Social Security [Card 181]
DISABILITY INSURED
a. requires between 6 (young ages) and 40 (age 62+) credits
b. If you need 20+, 20 must be from last 10 years
c. Between 6 and 20, at least HALF must be from age 21 or later
d. Need 6, all must be from last 3 years
FULLY INSURED
a. Credits = [Age - 22]
b. Minimum of 6 and max of 40
CURRENTLY INSURED
a. Need 6 credits in the 13 quarters ending with the quarter of death
b. Provides eligibility for young survivor benefits only
Eligibility and benefit amounts for Social Security disability and survivor benefits [Card 182]
Disabled-Worker Benefits
Eligibility - Must be disability and fully insured and unable to perform in any “gainful activity” (< $1000 per month)
Benefit - Calculated same way as retiree benefits (assumed age 62 and no early retirement reduction factor), but usually limited to 80% of average current earnings
Survivor Benefits
Eligibility - Family members may receive benefits as long as the worker was fully and currently insured at the time of death
Benefit - Worker has Primary Insurance Amount (PIA) which is computed using standard procedure and age 62
Survivors get a percentage of PIA
a. Children get 75%
b. Widowers get between 71.5% (@ 60) and 100% (@ 65) if not of retirement age. Increases linearly.
c. 82.5% for eligible surviving parent or 75% each for 2
d. MAX benefit applies of 175% of IPA
Individuals eligible for Medicare coverage [Card 183]
Acronym - A DOE
AGE into the pool - turn 65
DISABLED - entitled to disability benefits for at least two years
OTHER individuals who pay mandatory premiums
ESRD - insured workers with renal failure, including spouses and children with ESRD
Types of Medicare coverage and funding [Card 184]
Part A - Hospital Insurance
a. If eligible, get coverage automatically for no charge
b. Funded by 1.45% payroll tax, matched by employer
c. Includes coverage for IP, Skilled Nursing, Hospice
Part B - Supplementary Medical Insurance (SMI)
a. Requires monthly premium payments ($99.90 - 2012)
b. Higher income = additional payment (.9% payroll tax and 3.8% tax on investment income) starting in 2013
c. Can decline, but pay 10% penalty for each year you declined if you later decide you want it
d. Covers OP, ER, Ambulance
e. Financed through CMS (75%) and Premiums (25%)
Part C - Medicare Advantage
a. Alternative to Parts A and B, through private plans
b. Offer lower cost sharing and coverages not in A or B
Part D - Rx
a. Became available in 2006 bc of MMA
b. Through private insurers - offer PDP (standalone) or MAPD (Medicare Advantage) that provide both medical and drug coverage
c. Premium = 25.5% of standard benefit cost, and CMS pays the remaining 74.5%
d. Voluntary benefit, but must pay a penalty to enroll later than initial eligibility
Medicare Supplement - Medigap
a. Private insurance to cover OOP costs and other benefits not covered by Medicare
b. 10 plans available (A-N)
Services covered by Medicare Part A [Card 185]
Acronym - HISH
Hospice
Inpatient hospital benefits - semi private room and ancillary services/supplies
Skilled nursing facility - after related 3 day IP stay
Home healthcare - after discharge from hospital or SNF
Medicare Part A cost sharing and coverage limits [Card 186]
Coverage is tied to a “benefit period”
Benefit Period = Admission date to 60 days after discharge
Inpatient Hospital
a. Cost share = $1,156 deductible per benefit period
1. $289/day in days 61-90 each benefit period
2. $578/day for days 91-150 in lifetime reserve days
b. Coverage Limit = 60 lifetime reserve days, then 0
Skilled Nursing Facility
a. Cost share = $144.50/day for days 21-100 of each benefit period
b. Coverage limit = None after 100 days
Home Healthcare
a. Cost share = NONE
b. Coverage limit = 100 visits per illness
Hospice
a. Cost share = NONE
b. Coverage limit = NONE
Blood
a. Cost share = Cost of first 3 pints of blood
b. Coverage limit = NONE
Services covered by Medicare Part A [Card 187]
Acronym - PODR PHR HQWARTS (Harry Potter)
PHYSICAL therapy
OUTPATIENT hospital services
DIALYSIS
Rx - Self Injectables
PREVENTIVE services - no cost sharing
HOME healthcare not covered in Part A
REHAB
HTR QUALIFIED medical care WELLNESS physical @ enrollment AMBULANCE RADIATION therapy TRANSPLANTS SPEECH pathology
Medicare Part B cost sharing [Card 188]
Calendar year deductible = $140 in 2012
Coinsurance (after deductible) = 20% of the Medicare approved amount
NOTE: Coinsurance usually doesn’t apply to clinical lab and certain preventive tests
Approaches for improving Medicare solvency [Card 189]
Acronym - CRATIR (insolvent bc of a BIG hole)
Increase COST sharing through deductibles and copays REDUCE or eliminate services Raise eligibility AGE to 66 or 67 Increase TAXES INITIATIVES to lower trend - ACOs Adjust REIMBURSEMENTS to providers
Medicare provider reimbursement [Card 190]
Acronym - HOP
Hospital
a. Prospective payment basis
b. Paid a set amount per admit based on DRGs
c. Encourages efficiency since length of stay doesn’t increase the amount of money earned
Outpatient
a. Prospective payment system known as Ambulatory Payment Classification (APC)
Physician
a. Fee schedule
b. Reimbursement = ΣArea adj units * Conversion factor
Categories of Medicaid eligible individuals [Card 191]
Acronym - “Creepy Poor People Make Shitty Decisions”
Federal limits are set (2014 = 133% of FPL) for income and asset requirements
ACA: Feds will cover 100% of new members for 3 years, then phases down to 90% by 2020
States have their own programs which can be set at a higher level
Children Parents - or anyone with dependents Pregnant women Medically needy individuals Seniors Disabled people
Equivalence requirements for Part D employer group waiver plans (EGWPs) [Card 192]
Acronym - Have to be RICHER than Cat Deddy
Benefits must be at least as RICH as standard Part D
CATASTROPHIC coverage must be at least as rich as standard Part D
DEDUCTIBLE must be no greater than standard Part D
Types of Part D plans [Card 193]
Acronym - Marty Keegan
PDP - Private standalone plan that offers drug-only coverage
MAPD - Plan that offers both Rx and Medical coverage
Late enrollment penalty for Part D plans [Card 194]
Acronym - 1 Monthly Employer
Penalty is 1% of of base premium for every month they waited to enroll
Penalty is paid every month for the beneficiary’s lifetime
Penalty does NOT apply if individual has creditable coverage though another source (employer)
