Medicare & Medicaid Flashcards
What does Medicare Part A cover?
Inpatient care in hospitals, skilled nursing facility care, hospice care and home health care.
What is part of Medicare coverage is considered Hospital insurance ?
Medicare Part A
What does Medicare Part B cover?
Services from Doctors and other health care providers, outpatient care, home health care, durable medical equipment, Preventative services.
What does Medicare Part D cover?
Prescription Drugs, including many recommended shots or vaccines.
What is considered the original Medicare ?
Part A & Part B
What is Medicare Advantage known as?
Part C
What does Medicare Advantage cover?
In Network only providers and Doctors. It also covers vision, hearing, and dental services.
What is Medigap?
It is a Medicare Supplement Insurance that covers / or fills in the gaps in areas that the original Medicare doesn’t pay for such as copayments, coinsurance, and deductibles.
If you have Medicare Advantage, is it possible to purchase Medigap?
No
When is open enrollment for Medicare Part A & Part B coverage?
This is 3 months before you turn age 65 and 3 months after the month you turn 65. (7 month period)
Does Medicare Part A and Part B come automatically?
Only if you are already receiving benefits from social security or the Railroad retirement Board will you automatically get Part A and Part B starting the first day of the month you turn 65.
If I am not receiving Social Security or Railroad Retirement Board benefits when do I contact Medicare to sign up for Part A and Part B?
3 months before you turn 65.
What happens if you don’t sign up for Medicare Part B when you’re first eligible ?
You may have a late enrollment penalty of 10% for each full 12 months in the period that you could’ve had Part B. ** If there is a special enrollment period, you usually don’t have to pay a late enrollment penalty.
If you turn 65 on June 1st, the 7 month period would begin and end when?
It would begin in February and end in August.
If you sign up for Medicare Part A &/ or Part B during the first 3 months of the initial enrollment Period when would the coverage start ?
Coverage would begin the first day of the month of your birthday month.
What is Consolidated Omnibus Budget Reconciliation Act (COBRA)?
This covers retiree health plans, VA coverage, and individual health insurance through the insurance Marketplace after they have left the employment of their companies/line of duties.
Do you have to pay premiums for Medicare Part B?
Yes
When is General Enrollment Period for Part A & B?
January 1- March 31st each year.
If you sign up during the General Enrollment period when does your coverage start?
The first day of the month after you sign up.
Who is covered under TRICARE?
Active duty and retired service members and their families.
True or False: Are Medigap policies sold by private insurances companies ?
True
Does Medicare Part A cover the first 3 pints of blood?
No
What Medicare Supplement plan under Medigap covers the most?
Plan F
Which of the Medicare Supplement plans under Medigap cover the least?
Plan A
True or False: Before you can buy ad Medicare Supplement Insurance ( Medigap) you must have Part A & Part B ?
True
Is it illegal for someone to sell a Medigap policy if you already have a Medicare Advantage plan?
Yes, UNLESS you are switching back to Original Medicare.
If you have retiree health coverage who who pays first?
Medicare pays first
If you’re 65 or older, have group health plan coverage based on you or your spouse’s current employer that has 20 or more employees who is the first to pay ?
Your group health plan pays first.
If you’re 65 or older , have a group health plan coverage based on you or your spouse’s current employer that has fewer than 20 employees who is the first to pay ?
Medicare pays first.
If you’re under 65 and have disability with group health coverage based on you or a family members current employer and the employer has 100 or more employees, who is the first to pay?
Your group health plan pays first.
If you’re under 65 and have disability with group health coverage based on you or a family members current employer and the employer who has fewer than 100, who is the first to pay?
Medicare pays first.
If you have TRICARE who pays first ?
Medicare pays first, unless you’re on active duty.
If you have Medicaid who pays first?
Medicare pays first.
Under what circumstance is Medicare Part A premium- free?
When a individual is considered fully insured by working 40 credits while paying Social Security FICA taxes.
How many days are under the lifetime reserve days ?
60 Days
True or False: Medicare covers only medically necessary services?
True
What does it mean if a provider accepts an assignment?
It means that the provider has agreed to be paid directly from Medicare, to accept the payment amount that Medicare approves for the service.
Do you have to pay a deductible for a new benefit period?
Yes
If a doctor accepts the assignment, who submits the claim to Medicare ?
The Doctor/ their office
Providers who haven’t accepted an assignment for all services are called ________
Non-participating
If a provider does not accept an assignment is it possible that you will have to pay more for the service?
Yes
What are some of the different types of Medicare Advantage plans ?
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Private Fee-for-Service (PFFS)
To join a Medicare Advantage Plan you must have what (hint: 3 specific things)
- You must be a citizen
- You must have Part A & Part B
- You must live in the plan’s service area.
Under the Medicare Advantage Plans: With Health Maintenance Organization plans (HMO) are you able to pick any provider/ Doctor?
No, the provider/doctor must be in network. (Except for emergency care)
Under the Medicare Advantage Plans: With Health Maintenance Organization plans (HMO) do you need a referral to see a specialist?
Yes, in most cases.
Under the Medicare Advantage Plans: Can you choose any provider/Doctor with a Preferred Provider Organization (PPO) ?
Yes, you can use in network and out of network providers for covered services, usually for a higher cost.
Under the Medicare Advantage Plans: Do you need a referral to see a specialist if you have a Preferred Provider Organization (PPO) ?
No, but if you use in network specialist, your cost for covered services will usually be lower than the out of network specialist.
Under the Medicare Advantage Plans: Are you able to select any provider/ doctor while having a Private Fee - for - service (PFFS) plan?
Yes
How is Medicare funded ?
By the Centers for Medicare and Medicaid services (CMS) which is a branch of the Dept of Health and Human resources.
If the provider does not accept a Medicare assignment who is the bill sent to?
The patient
If the provider does not accept a Medicare assignment who is responsible to fill out the claim form with the itemized bill?
The patient
When should the buyers guide that was developed by the NAIC be given to a person ?
At the time of the application delivery.
Under the Medicare Supplement policies: Applicants must be given a Outline of Coverage that describes what ?
The policy’s coverage, the premium and renewal provisions.
Under the Medicare Supplement policies: Applicants first page if the policy must contain what?
- Notice to Buyer ( it may not cover all medical expenses)
- 30 day free look
- The policy’s renewal provision including a description of any premium increases that may be involved
True or False: With Medigap, pre-existing conditions may not last longer than 6 months from the date of issue?
True
What are the eligibility requirements for Medicare coverage?
Age 65 or older
Kidney failure (end stage renal disease)
Received SS disability for at least 24 months
For Medicare Part A, how many days of the hospital stay are covered ?
90 days
For Medicare Part A, how many days in a Skilled nursing facility is paid at 100% by Medicare ?
Days 1-20
After 100 days in a Medicare qualified skilled nursing facility who is responsible to pay for the expenses?
The patient, Medicare stops paying for the facility after 100 days
True or False: Medicare Part B is required ?
False
Who funds Medicaid ?
By the State and Federal government
How do you qualify for Medicaid?
Low income/ the needy, U.S citizens and disabilities.
They must qualify for Temporary assistance for the needy families (TANF) or Supplemental Security Income (SSI) 65 or older, blind, or disabled.
What is the largest payor of health care cost?
Medicaid
What is Program of all-inclusive care for the elderly (PACE)?
It is a Medicare and Medicaid program offered to people who otherwise need a nursing home level of care to remain in the community like home/ or apartment.
True or False: Medicare covers custodial care ?
False
