MEDICARE (4 QUESTIONS) Flashcards
How old do you have to be in order to be eligible for medicare?
65 or older
Who else can be covered by Medicare besides 65 year olds?
Certain people under 65 with disabilities and people of any age with end state rental disease (permanent kidney failure requiring dialysis or a kidney transplant)
What are the two main ways to get medicare coverage?
Original Medicare and Medicate Advantage
Is Medicare part of the social security system?
Yes - it’s tied almost directly to eligibility for social security benefits
What 3 major programs does original Medicare consist of?
- Medicare Part A – Hospital Insurance
- Medicare Part B – Medical Insurance
- Medicare Part D – Medicare Prescription Drug Coverage
What is covered under Medicare Part A – Hospital Insurance
- Impatient care in hospitals
- Skilled nursing facility care (short term)
- Hospice care
- Some home health care
How is Medicare part A hospital insurance financed?
Part A program is financed through a 2.9% payroll tax on all wages and self-employment income.
What is covered under Medicare Part B - Medical Insurance?
- Services from doctors and other health care providers
- Outpatient care
- Home health care
- Durable medical equipment (wheelchairs, hospital beds)
- Many preventive services (annual wellness visits, shots, screenings)
How is Medicare Part B - Medical Insurance financed?
Part B is financed through monthly premiums and general Federal revenues, rather than by payroll tax.
Part B enrollees pay a monthly premium that is adjusted annually that covers 25% of program’s costs. The federal government covers 75% of Part B’s costs from general tax revenues.
What is covered under Medicare Part D – Medicare Prescription Drug Coverage?
- Cost of prescription drugs
- Run by Medicare-approved drug plans (run by private insurance companies) that follows rules set by Medicare
- May help lower your prescription drug costs and help protect against higher costs in future.
- Extra held is a medicare program to help people with limited income and resources to pay medicare prescription drug program costs
Which parts are included in original Medicare?
Original Medicare includes Part A and B. If you want drug coverage you can join a separate Part D plan.
What can you do to pay out of pocket costs?
To pay out of pocket costs (like 20% coinsurance) you can shop for and buy supplemental coverage (i.e. Medigap). With Original Medicare you can go to any doctor or hospital in the US that takes Medicare.
What is Medicare advantage part C?
- Part C is “Medicare Advantage,” which is a variant of managed care in the context of Medicare or some other alternative.
- It is an “all in one” alternative to Original Medicare and these bundled plans include Part A, B and usually D.
- In most cases, you’ll need to use doctors who in the plan’s network.
- Most plans offer extra benefits like vision, hearing, dental and more
What are the types of Medicare Advantage Plans?
- HMO: Medicare Health Maintenance Organizations
- PPO: Preferred Provider Organization (PPO
- PFFS: Private-Fee-for-Service (PFFS) Plan.
- SNP: Special Needs Plan (SNP).
What is an HMO Medicare Health Maintenance Organizations ?
Provides all the services to the enrollee as determined by the HMO without deductibles, limitations and copayments but enrollee is limited to a specified group of physicians, doctors, pharmacies. Many HMOs cover dental, eye care, hearing aids.
What is PPO Preferred Provider Organization ?
This covers services rendered by designated health care providers and covers part of cost of services by other providers. The patient then pays the remainder of costs incurred.
What is PFFS: Private-Fee-for-Service (PFFS) Plan?
You can go to any Medicare-approved doctor or provider or hospital that accepts the plan’s payment terms and agrees to treat you.
What is SNP: Special Needs Plan?
Provides benefits to people with specific diseases, needs or limited income
Who is eligible for Medicare?
- Any person who is 65 years old AND is eligible for SS benefits is entitled to Medicare Part A without charge.
- Persons who have received Social Security disability payments for at least 24 months;
- Persons with “end state renal disease.”
In order to receive Medicare benefits, what must you do if you are close to 65 and not getting SS benefits?
You will need to sign up for Medicare.
Contact SSA 3 months before 65th birthday.
A person does not need to be actually collecting SS benefits to be entitled to enroll in Medicare (i.e. you have not retired or you have deferred social security, but still entitled to Medicare Part A).
However, you must be 65 (i.e. you can receive SS benefits at 62 but not eligible for Medicare).
Can you receive Medicare at age 62 if you elect ss benefits early?
NO
If you are already receiving social security benefits at 65 (i.e. you started receiving it early) what must you do to obtain Medicare at 65?
If you are already getting SS benefits, you will automatically get Part A and B starting the first day of the month you turn 65
Can you receive Medicare benefits if you are 65 or over and not entitled to SS benefits but reside in the US (and have been for the preceding 5 years) and either be a citizen or resident alien?
YES - you can enroll and pay a fee. However, these individuals have to enroll in Part A and B coverage. However, if you enroll in Part B you don’t have to enroll in Part A.
If you are a spouse or widow of someone who was eligible for SS benefits, what if anything are you entitled to?
A spouse or widow of someone who was eligible for SS benefits is also entitled to Medicare Part A but that spouse or widow must also be age 65 or older (younger spouse gets no coverage)
What are the requirements for a former spouse to qualify for medicare under their former spouse’s entitlement?
A divorce spouse married to someone 10 years or more and who has not remarried can qualify for Medicate via former spouse’s Medicare entitlement. Doesn’t matter if former spouse remarried (i.e. Jonnie Carson’s wives all could claim Medicare so long as they had not remarried and had been married to JC for 10 years or more).
Is there any incentive to hold off on enrolling in Medicare at 65?
Upon turning 65 a person should enroll in Medicare because there is no financial incentive to defer enrollment.
What is the incentive to enroll right away at 65 for Medicare?
In most cases if you don’t sign up for Part A and Part B when you’re first eligible, you may have to pay a late enrollment penalty.
Is their always a late enrollment fee if you don’t enroll right at 65?
You don’t usually pay a late enrollment penalty if you sign up during a Special Enrollment Period (i.e. if you didn’t sign up for Part B when you were first eligible because you are covered under your spouse’s group health plan you can sign up for Medicare A and/or B anytime you’re still covered by the group health plan).
When can you sign up if you didn’t sign up for Part A and/or Part B during Initial Enrollment and you don’t qualify for Special Enrollment?
You can sign up between January 1 – March 31 each year.
When can you change your Medicare health or prescription drug coverage for following year if you decide?
October 15 to December 7th
If you make a change to your Medicare coverage, when does it begin?
January 1st
If you’re in Medicare Advantage, you can make a change to a different Medicare Advantage or switch bank to Original Medicare during what period of time?
January 1st to March 31st –
Is there a waiver of patient liability under Medicare coverage?
YES - Medicare holds patients harmless in certain circumstances even if Medicare does not cover the services being disputed. In these situations, the health services provider suffers the economic loss, not the patient. This applies if a patient did not know or could not have been expected to know that Medicare would refuse to pay for the services
What does medigap apply to?
Applies to Original Medicare and NOT Medicare Advantage Part C (you cannot enroll and don’t need Medicare Supplemental Insurance aka Medigap policy while you’re in a Medicare Advantage Plan; it is illegal to see someone Medigap if they are in a Medicare Advantage Plan).
What costs can medigap cover
Certain medic costs are not paid by Medicare or only in part and private insurance companies have developed Medigap policies to cover differential costs that Medicare doesn’t cover
Can medigap deny coverage for a prexisting condition?
Cannot be denied policy because of a pre-existing condition if that person applies during the first 6 months of enrollment in Medicare Part B. this protection generally does not apply after that time.
What coverage is not included in medigap?
Vision care, eyeglasses, hearing aids and dental care are not covered, nor is custodial care coverage after the first 100 days (in a nursing home, and one would need long term care insurance).
What is medicaid?
Another governmental health care financing program. This is not limited to older people but applies to low income persons of any age and covers certain costs, primarily long term institutionalization, that Medicare generally does not. Because of this extensive coverage, some older people will need to consider Medicaid in addition to Medicare. If you have Medicaid, you should sign up for Part B. Medicare will pay first, and Medicaid will pay second. Medicaid may be able to help pay your Medicare out of pocket costs like premiums, copays, etc.
Can you contribute to HSA once your Medicare coverage begins?
NO- You cannot contribute to HSA account once your Medicare coverage begins, but you can use money already in account to help pay deductibles, premiums, copayments or coinsurance.
