Lecture 3: Medicare Flashcards
Who is covered under medicare part A?
- 65 and older
- US Citizens
- Permanent legal residents (at least 5 years of continuous residence)
- Qualify w/o regard to medical hx, pre-existing conditions or income/asset test
- People under age 65 with ESRD and ASL
- Permanent disabilities after receiving SS Disability insurance (SSDI) payments for 24 mos.
Who is covered under Medicare Part B?
Part B is voluntary, if you are eligible for Part A, you are eligible for part B
i. if enrolled in Part A, automatically enrolled unless declines
- more than 90% of people have part A and B
Who is eligible for medicare part C?
If entitled to part A and enrolled in Part B, individuals may choose to enroll in part C
Who is eligible for medicare part D?
Available to all 55 million elderly and disabled beneficiaries through private plans if enrolled in Part A, Part B, or both.
What does dual eligible mean?
Qualify for both medicaid and medicare
Dual eligible individuals are enrolled in Medicare Part A (Hospital insurance) and/or Part B (Supplemental Medical insurance) and area also enrolled in full-benefit medicaid
What is medigap?
Helps pay some of the remaining health care costs (copays, coinsurance, deductibles, medical needs when traveling)
How is medigap paid for?
Pay the private insurance company a monthly premium for your Medigap plan in addition to the monthly part B premium you pay to medicare. Medigap plan only covers one person (each person has to buy separate policies for Medigap)
What is the coverage gap called within the standard benefit under the Medicare Part D program?
“Donut holes” – enrollee pays 25% (co-insurance) and plan 75% (for drug costs between $4130 and $6550)
Government not allowed to negotiate w/ pharmaceuticals for lower drug prices
High deductible & cost sharing requirements
No limit on out-of-pocket spending
There’s a temporary limit on what the drug plan will cover for drugs.
not everyone will enter the coverage gap.
The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
Main coverage under part A?
Inpatient hospital stays:
Semi-private room, meals, general nursing, drugs
SNF:
Semi private room, meals, skilled nursing, OT/PT/Speech – if needed to meet health goals, social services, meds, medical supplies, ambulance, dietary counseling
Hospice care:
MD, nursing, medical equipment and supplies, drugs, hospice aide, PT, OT, Speech, social services, grief and loss counseling, short term inpatient care for pain and symptom management.
Post-acute home health care:
Covers home health services like intermittent skilled nursing, OT, PT, Speech
Main coverage under part B
Outpatient services
Outpatient hospital care
Physician & Preventive services
Ambulance services, labs, DME, kidney supplies, outpatient mental health, diagnostic testing
Payment
Pay a monthly premium ($148.50 in 2021; higher for larger income)
Annual deductible ($203 in 2021)
Co-insurance (20% after deductible for the year is met)
Main coverages under part C?
Covers all benefits under Medicare A, B & in most cases D through a private health plan (e.g., HMO or PPO)
Receive extra benefits (e.g., eye glasses, hearing exams, dental, podiatry, chiropractic, and gym memberships)
Main coverage under part D?
Drug coverage
What DME is covered under Medicare
Covered through part B
Required for coverage:
Doctor prescription
Durable
Used for medical reasons
Used in the home
Has expected lifetime of at least 3 years
Canes, walkers (including rollators)
Commodes
Hospital Beds
Some Wheelchairs and Power mobility
Will not cover:
Tub bench, shower chair, raised toilet seat, grab bars, high end hospital beds, limited W/C, any home modifications (no waiver programs)
How is driving rehab covered under medicare?
Only in clinic eval
Doesn’t cover on the road assessment or adaptive equipment.
What does the repeal of the OT cap for Medicare B mean?
Caps for treatment have been removed (used to be a cap on how much outpatient therapy a beneficiary can receive each year regardless of medical necessity)
