Medicare and Medicaid Flashcards
Medicare pays a large portion of the health care bill for persons who:
-are age 65 or over
-have end-stage renal disease
-have been receiving Social Security disability benefits for at least 24 months
Qualification for Medicare requires:
-individual to be “fully insured” according to social security
-accumulating at least 40 credits by generating a minimum amount of work-related income over at least the past 10 years and paying social security (FICA) taxes
Private healthcare insurance companies process medical claims for Medicare and are known as:
Medicare Administrative Contractors (MAC)
The initial enrollment for Medicare is a _____-month prior that begins _____ months before the month an individual turns 65, includes the month they turn 65, and ends ___ months after the month they turn 65
Seven; three; three
Medicare part A covers:
Hospital, skilled nursing facility, hospice, and home health care
Medicare part B covers:
Medical care provided by physicians and other medical servicesp
Medicare part C covers:
Health care delivered by managed care plans
Medicare part D covers:
Prescription drugs
For people age 65 and covered by Social Security, enrollment in Medicare Part A is _______ on the first day of the month that they reach age 65 and is _____
Automatic; free
Medicare Part A hospital coverage is based on _______ _______ rather than the calendar year
Benefit periods
A Medicare part A inpatient hospital benefit period begins when:
Someone is admitted to the hospital and ends 60 days after discharge
For each Medicare part A inpatient hospital benefit period, coverage and cost-sharing amounts are as follows:
-the patient pays a deductible, which changes annually
-days 1-60: fully paid by Medicare (after the deductible)
-days 61-90: Medicare pays most of the cost, and the patient pays a daily co-pay amount which changes each year
_______ care and _______ care are NOT covered by Medicare
Intermediate; custodial
Medicare covers skilled nursing facility care if:
-it is a Medicare-approved facility
-the SNF stay begins immediately after release from a hospital stay of at least 3 days
Medicare coverage and cost-sharing amounts for a skilled nursing facility are:
-day 1-20: fully paid by Medicare
-days 21-100: Medicare pays most of the cost and the patient pays a daily co-pay amount which changes each year
-after day 100, Medicare pays nothing
If a patient is confined at home, Medicare Part A’s home health care benefit covers:
-visits by a home health aide to provide medical services such as part-time nursing care and physical, occupational, or speech therapy
-80% of the cost of durable medical equipment such as hospital beds or wheelchairs
Medicare part A exclusions:
-first 3 pints of blood
-private duty nursing
-non-medical services
-intermediate care
-custodial care
Individuals who enroll in Medicare Part A are ______ enrolled in Part B unless they request otherwise
Automatically
Medicare Part B is ______ and required a monthly ________
Optional; premium
The Medicare Part B premium is tied to;
An individual’s income level and is deducted from the social security monthly benefit check
If an individual initially declines Medicare Part B enrollment, they can enroll during the general enrollment period that occurs each year from ______ _ through _____ __ and coverage starts at the beginning of the following month
January 1; March 31
Medicare Part B provides coverage for 3 general kinds of medical services:
Inpatient and outpatient physician services, home health care if not covered by Part A, and outpatient medical services and supplies
Some preventative care is included under Medicare Part B:
-an initial routine physical exam within the first 6 months of enrollment
-screening tests for cholesterol, diabetes, and colorectal cancer
-annual mammograms (age 40+), Pap tests, pelvic exams, and clinic breast exams for women
-annual prostate cancer screenings for men age 50+
-glaucoma testing one ever 12 months
-Bone mass measurements for qualified individuals
-flu shots
Medicare part B has an annual deductible that changes each year and also a __% coinsurance
20
Medicare assignment
Means that the doctor or supplier will accept Medicare’s approved amounts as full payments and cannot legally bill the patient for anything above that amount
Medicare Part B exclusions:
-routine foot, vision, dental or hearing care
-most immunizations
-most outpatient prescription drugs
-physician charges above Medicare’s approved amount
-private-duty nursing
-cosmetic surgery
-most care received outside the US
-expenses incurred as a result of war or act of war
Medicare beneficiaries can choose to receive their benefits from a Medicare Advantage plan but they still must:
Enroll in Part A, Part B, pay the Part B premium, and pay the Medicare Advantage Plan Premium
Medicare Part C- Advantage Plans
-Medicare contracts with and pays private companies
-enrollees medical expenses paid by the private plan
-enrollee must be enrolled in Medicare part A & B
-private company may charge the enrollee a fee
-may provide outpatient drug coverage
There are four types of Medicare Advantage Plans:
-Medicare-managed care plans
-Medicare preferred provider organization plans (PPO)
-Medicare private fee-for-service (PFFS) plans
-Medicare specialty plans
Medicare Part D costs:
-a monthly premium- high income beneficiaries may be a relatively higher premium
-an annual deductible with a max amount- not all PDPs have a deductible, or charge the max deductible
-25% coinsurance- until total expenditures reach the threshold amount for the coverage gap
Beginning in 2020, once the insured reaches the Medicare coverage gap, they will pay no more than __% of the cost for the plan’s covered brand-name prescription drugs and generic prescription drugs
25
If individual is over 65 and works for an employer with less than 20 employers that sponsors a group plan, Medicare is the ________
Primary
A Medicare supplement insurance (Medical) policy, sold by private companies, can help pay some of health care cost that Original Medicare doesn’t cover like:
Co-payments, coinsurance, and deductibles
Medigap policies must be at least _______ ________
Guaranteed renewable
Medigap policy benefits must be __________ _______ for changes in Medicare
Automatically adjusted
Medigap policies may not _________ benefits provided by Medicare
Duplicate
Medigap policies must have a __-day free look period
30
If a Medigap policy is replaced, the applicant must be given:
-a refund of unearned premium on the replaced policy
-credit under the new policy for any time elapsed under the pre-existing condition provision of the replaced policy
Medicare SELECT is coverage offered through:
A restricted provider network, like a managed care plan
Insurers may not sell Medicare SELECT policies to individual’s outside:
The network service area
Medicare SELECT policyholder must have the option to switch to:
A Medigap policy without a restricted provider network
To receive Medicaid, a person must qualify for:
-Temporary Assistance for Needy Families (TANF/Welfare)
-supplemental security income (SSI) assistance program for people living at or near the poverty line who are age 65+, blind or disabled
