Medicare Flashcards
what is SHIBA?
part of state health insurance assistance programs (SHIP)
centers for medicare and medicaid services
what is SHIBAs mission?
to educate and advocate for medicare beneficiaries about their rights and options to help make informed decisions
what does part A cover?
inpatient care
skilled nursing care
home health care
hospice care
what does part B cover?
doctors services & outpatient surgeries preventative services diagnostic tests some drug therapies administered by dr medical equipment
T/F you must have been a US citizen or legal resident in US for 5 years to be eligible for Medicare
True
T/F you can be automatically enrolled in medicare if you’re receiving social security benefits
True
can you enroll into part A without enrolling into part B?
Yes
when is the initial enrollment period? when does enrollment begin?
3 months before the month you turn 65.
begins first day of the month you turn 65
or
you can apply during the month of your birthday and receive benefits the month after birthday
or
up to 3 months after turning 65, enrollment will be delayed 2-3 months
when is the general enrollment period? when does it take effect?
january-march of each year.
starts july of the year you enroll
if you enroll into medicare over 3 months after your birthday and you are not in the months january-march, how long until you can get medicare benefits?
must wait to apply in january to become enrolled in july
can you wait to enroll into part B and D if you have other employer coverage at 65?
Yes
why is it recommended to enroll into part A even if you have employer ins?
theres no premium
if fewer than 20 employees at your job, why should you get part B?
medicare acts as primary payer and employer ins acts as a secondary
what is the special enrollment period (SEP)? (part B)
if you’re getting part B late due to employment you qualify for SEP which allows you to enroll for up to 8 months from loss of ins
what is the penalty for not enrolling into part B when suggested?
current premium rate + 10% for each year delayed, payed for LIFE
does COBRA ins count as part B or D exemption?
no
if you are on medicaid can you stay on it turning 65 instead of going onto medicare?
no, you must apply for medicare and then you can additionally reapply for medicaid
can VA insurance replace part B?
no
how do you qualify for premium-free part A?
10 years of work history or 40 quarters
does your spouse qualify for premium-free part A as well?
yes if married over 5 years
two ways for low-income people to pay for part B premium?
with social security pension
qualify for medicaid state may pay
Which shots does part B cover?
flu
pneumococcal
hep B
how can you pay for things not covered by medicare?
private insurance - supplement insurance (medigap)
medicare advantage plans
tricare/VA
medicaid
what is a medigap plan?
provided by private companies
pays what medicare doesnt cover
plans A-N
no drug coverage
what is the initial enrollment period for medigap?
up to 6 months after enrolling in medicare part B
qualifications for special enrollment for medigap:
disabled, turning 65
loss of coverage out of your control
first 12 months in a medicare advantage plan at 65
T/F you cannot be denied when applying outside of the guaranteed issue period due to pre-existing medical issues (underwriting)
False, you CAN be denied
what is Oregon’s “birthday rule” for people who already have medigap?
beginning on someones birthday and for 30 days after they can change plans without underwriting
what is medicare part C?
private advantage plan, acts as primary payer for medical services and usually includes prescription drug coverage
PPO vs HMO Medicare
PPO: any provider that accepts medicare
HMO: usually need a referral to see a specialist, must choose a PCP in network
when is initial enrollment period for advantage & drug plans?
same as part B or 60 days after employer plan ends
when is Annual election period for advantage & drug plans?
oct 15- dec 7
qualifications for Special enrollment periods for advantage plans:
move out of plan’s service area
plan leaves your service area
if you qualify for extra help
if employer coverage ends or you quit working
Medigap plan vs Advtantage plan: premiums
medigap has higher premiums
Medigap plan vs Advtantage plan: drug coverage
medigap: none (except PERS)
advant: yes
what are some other coverage options for plans that have medicare-specific options?
PERS, Union, Federal Retirees
if you have VA ins or tricare for life, what other supplementation are you still required to obtain for medicare?
part B
what are the two types of drug coverage options? (medicare)
- original medicare
- medicare advantage prescription drug plans
what is the part D waiting to enroll penalty?
1% premium increase for every full month
delayed– beginning 3 months after turning 65 or
6 months after leaving employer plan
list the co-payment “tiers” and their general meaning
tier 1: low cost generics tier 2: high cost generics tier 3: comon "preferred" brand drugs tier 4: higher cost brand drugs tier 5: specialty drugs
can you have a monthly premium for part D?
yes
can you have a annual deductible for plan D?
yes
how much is your typical co-pay after the initial benefit period after deductible for part D?
25%
what is the part D “coverage gap” or “donut hole”?
after client and ins have paid a fixed amount, then client pays 25% for all drugs
what is part D “catastrophic coverage”
after client has paid a fixed amount max co-pay is 5% or fixed low cost
when is initial enrollment period for part D?
7 month period around 65th birthday (same rules as part B)
when is the fall annual enrollment period for part D?
oct 15 - dec 7
when is special enrollment period for part D?
60 days after retirement or moving
jan 1 - feb 14 if disenroll from an advantage plan
does max out of pocket for medical costs apply to part D portion of advantage plan?
no
when can a low-performing drug plan be terminated?
if plan receives a score of less than 3 stars for 3 consecutive years
what is limited income subsidy? (LIS)
federal program by social security for prescription drug assistance
-typically pays entire part D premium
what is medicare savings plans (MSP)
do people using MSP qualify for LIS?
medicaid plans
pays part B premiums
-yes
T/F people on LIS have continuous open enrollment priviledges
true
what is the full dual medicare savings program?
similar to OHP: includes medical costs and dental benefits
what is the qualified medicare beneficiaries (QMB)?
covers part B premiums, , deductibles and co-pays (cost sharing) paid by the state. no dental
SMB/SMF and QI: what does it pay for?
part B premium and drugs, not medical
what did the affordable care act change for medicare?
- inc access to preventative care
- inc # of beneficiaries paying higher part B premiums
- close part D coverage gap (donut hole)
- others, refer to week 3 slide 4
biparitsan budget act of 2018: what happened in 2020?
part D enrolless pay 25% now
Summarize Part A: Primary use Premium Deductible (60-day benefit period) When do you pay co-pays
Hospital insurance
Free for most
~$1450 for each 60-day benefit period
Co-pays after 60 days
Summarize Part B: Primary use Premium Deductible (per year) Co-insurance
Outpatient medical insurance
~$150/month
~$200 per year
20%
Summarize Supplement/Medigap Plans What are the choices? Which plan is most comprehensive? Which plans were discontinued in 2020? Does it include drug coverage? Most people need to buy what Medicare plan with it? High/low premium? Is there a co-pay? Nationwide coverage?
Plans A-N Plan G Plans C and F No Part D High premium No co-pays Yes
Summarize Medicare Advantage Plans What are the choices? Does it include drug coverage? High/low premium? Is there a co-pay? Nationwide coverage?
PPO or HMO plans Yes Low premium Yes No, best for in-network providors
