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Disability Income Insurance > Senior Care > Flashcards

Senior Care Flashcards

1
Q

What are the three policies that would make Medicare primary

A
  • Individual policy (Medicare is primary)
  • Medicare supplement
  • Medicare carve-out plan (in a small group)
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2
Q

When is Medicare secondary

A
  • Employer has at least 20 employees and the employee is enrolled in active group coverage (he doesn’t want Medicare)
  • Employer has at least 100 employees and the employee is under 65 and qualifies for Medicare due to a disability
  • When an employee qualifies for Medicare due to permanent kidney failure (Medicare is secondary for the first 30 months and then will become primary)
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3
Q

What is Medicare Part A for

A

In-patient hospitalization

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4
Q

What covers the cost of Part A

A

It is through the Social Security tax during a person’s working years

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5
Q

When is enrollment automatic in Part A

A

Age 65 and you have been receiving SS or Railroad Retirement benefits before 65 or you have been receiving SS or RR disability benefits for 24 months

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6
Q

When is the initial enrollment period (IEP)

A

It is a seven month period starting three months before your 65 birthday and three months after your 65 birthday

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7
Q

When is the annual general enrollment period (AEP)

A

First three months of the year (January - March)

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8
Q

Define the special enrollment period (SEP) for Part A and B

A

If you are 65 years old and your group coverage is terminated, then you have an 8 month period that begins in the month after your employment ends or the group plan ends to enroll

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9
Q

What does Medicare Part A cover (4)

A
  • Semiprivate room
  • Regular nursing
  • Intensive care
  • Drugs and labs administered in the hospital
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10
Q

What are 4 things that Part A does not cover

A
  • Private room (unless medically necessary)
  • Private nursing
  • Physician
  • Surgeon
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11
Q

How many days is a person eligible for coverage in each benefit period

A

Up to 90 days

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12
Q

When is the benefit period (Part A)

A

Begins with admittance to the hospital and ends when the patient is out of the hospital for 60 days

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13
Q

What if the patient re-enters the hospital within 60 days

A

Then there is no additional deductible

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14
Q

Is there a deductible for Part A

A

Yes, there is a deductible at the start

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15
Q

When does coinsurance kick in for Part A

A

61-90 days in the hospital

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16
Q

What if a person is hospitalized for more than 90 days

A

Then they can use their reserve days

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17
Q

How many reserve days does each person have

A

60 days

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18
Q

Does coinsurance apply to reserve days

A

Yes

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19
Q

How many days will Part A cover for psychiatric hospital care

A

190 days

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20
Q

How does Medicare pay hospitals

A

Prospective payment system

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21
Q

How does the Prospective payment system work

A

A patient is diagnosed with a diagnosis related group (DRG) and then the hospital is paid based on that DRG, regardless of the actual length of stay or cost of treatment

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22
Q

What part is skilled nursing covered under

A

Part A

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23
Q

What are 4 things that are required at SNFs

A
  • Provide care under the supervision of a doctor
  • Have a doctor available for emergency
  • Provide 24 hour nursing
  • Have at least one full-time RN
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24
Q

In order to have Part A cover SNFs, what must happen

A

The patient has to be admitted to a SNF within 30 days after at least staying in the hosptial for 3 days

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25
Q

How many days will Part A cover in a SNF

A

100 days during a benefit period

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26
Q

Is there a deductible for a SNF under Part A

A

No

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27
Q

When does coinsurance kick in for a SNF under Part A

A

For days 21-100

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28
Q

Besides hospital and SNF, what are 3 other services that are covered under Part A

A
  • Home Health Care
  • Hospice Care
  • Respite Care
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29
Q

What is covered under Home Health Care for Part A

A
  • Unlimited number of days (including speech and PT)
  • Part time care
  • Cannot be more than 6 days per week
  • Cannot last for more than 3 consecutive weeks
  • No limit on the total number of visits
  • No limit on the total number of weeks
  • No deductible
  • No coinsurance
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30
Q

If a patient does not have Part A, will home health still be covered?

A

Yes, it will be covered under Part B (if they have it)

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31
Q

Does Medicare home health care cover custodial

A

No

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32
Q

When is hospice used

A

If you have 6 months or less to live

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33
Q

What is covered under hospice for Part A

A
  • No deductible
  • No coinsurance
  • Includes doctor, nursing care, pain relief, homemaker services and respite care
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34
Q

Define respite care

A

Provide care in a hospice up to five consecutive days in order to provide relief to a person caring for the terminally ill patient

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35
Q

In short, what does Part B cover

A

Non-hospital coverage (supplementary medical insurance)

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36
Q

Is there a premium for Part B

A

Yes, it is voluntary, so there is a premium

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37
Q

Can you re-enroll in Part B

A

yes

38
Q

Is Part B automatically provided with Part A

A

Yes, it is automatically provided with Part A and you have to decline it if you don’t want it

39
Q

When can enrollment into Part B be delayed

A

When employer coverage is primary

40
Q

What are 5 things that Part B covers

A
  • Physician and surgeon services
  • Outpatient and emergency room services
  • Home Health, if not covered by Part A
  • Ambulance
  • Braces, artificial limbs, pacemakers
41
Q

What are 6 things that Part B does not cover

A
  • Custodial care
  • Eyeglasses and hearing aids
  • Cosmetic surgery
  • Dental care
  • Checkups
  • Drugs that can be self-administered
42
Q

What are three costs, besides premiums that a beneficiary must pay under Part B

A
  • Deductible
  • Coinsurance
  • First 3 pints of blood
43
Q

How much will Part B pay

A

80% of their “allowable charges” based on the Medicare Approved Amount

44
Q

Is Medicare based on usual and customary charges

A

No, it is based on the Medicare Approved Amount

45
Q

What does Medicare Part C cover

A

It covers the gaps between Part A and Part B

46
Q

What types of things does Part C cover

A
  • Long-term nursing
  • Custodial
  • Denture/dental care
  • Eyeglasses
  • Hearing aids
  • Drugs
47
Q

When can a person enroll in Part C

A
  • When they become eligible

- During open enrollment from October 15 - December 7th

48
Q

If a private company wants to offer Part D plans, what do those plans have to be

A

They have to be at least as good as Medicare’s standard benefit design plan

49
Q

What does a member pay under Part D

A
  • Premium
  • Deductible
  • Co-pay
50
Q

When can a person enroll in Part D

A
  • When they become eligible

- During open enrollment from October 15 - December 7th

51
Q

Define creditable drug coverage

A

When expected average drug payments paid by the plan are the same or higher than the standard Medicare drug coverage

52
Q

What is the penalty if you do not enroll in Part D when your first eligible, and instead enroll at a later date (for Medicare eligible members who have non-creditable coverage)

A

They have an annual premium penalty of 1% for each month of delayed enrollment

53
Q

What does a person pay if they see a non-participating provider for Medicare

A

They pay the entire charge, then get reimbursed from Medicare on the portion that they would have covered had they been participating, and then pays the rest OOP (balance billing)

54
Q

What can non-participating providers charge Medicare patients

A

Up to 115% of the charge

55
Q

Define Medicare Summary Notice (MSN)

A

Itemized summary of services provided from the preceding quarter

56
Q

Define intermediaries

A

Insurance companies that have a contract with CMS and handle claims from hosptials, SNFs, Home health and hospice for Part A

57
Q

Define carriers

A

Insurance companies that have a contract with CMS and handle claims from doctors and other providers of Part B and Part D services

58
Q

If a new enrollee in Part B joins and wants to enroll in Part D, can they enroll during a Special Enrollment Period (SEP)

A

Yes, they can enroll in Part D during April - June

59
Q

What gaps in coverage do Medicare Supplement policies (Medigap) cover

A
  • Deductibles
  • Coinsurance
  • Charges above the Medicare limits
  • Cost of additional uncovered services
60
Q

When is the open enrollment period for Medicare Supplement polcies (Medigap)

A

Six month period after an applicant turns 65 and is enrolled in part B or becomes enrolled in Part B without regard to age

61
Q

What does OBRA stand for

A

Omnibus Budget Reconciliation Act

62
Q

What does OBRA require from insurers

A

It requires insurers to provide a six-month open enrollment period of which they cannot deny coverage due to a medical condition

63
Q

Under OBRA, can pre-existing conditions be excluded

A

Yes temporarily

64
Q

How many Medigap plans are insurance companies limited to sell

A

They can only offer 14 plans and they all must include core benefits

65
Q

What Medigap Plan are all insurance companies required to sell

A

All have to have Plan A (core package) plus either Plan C or Plan F

66
Q

To be eligible for Medigap, what must a person be enrolled in

A

They have to be enrolled in both Part A and Part B

67
Q

Define a pre-existing condition exclusion under a Medigap policy

A

The exclusion can only relate to a medical treatment that the insured received within 6 months before their enrollment and may only exclude coverage for that condition no more than 6 months after the effective date

68
Q

Is there a requirement to issue Medigap policies to persons under 65

A

No

69
Q

What are the letters of the Medigap policies offered

A

Plans A - N

70
Q

Is there a difference between the plans offered from different insurance carriers

A

No, for example, all Plans A will provide the same exact benefits regardless of who is selling them

71
Q

What is the difference between the Medigap Plans offered from different insurance carriers

A

Premiums, coverage is the same

72
Q

List the 5 core benefits that all insurance carriers must offer in Plan A

A
  • Medicare Part A coinsurance
  • Additional 365 days of hospital coverage paid at 100%
  • Medicare Part B coinsurance
  • Cost of 3 pints of blood
  • Part A hospice coinsurance
73
Q

What plans are considered catastrophic plans

A

M and N

74
Q

What plans are no longer sold (but members can still keep them if they had them)

A

E, H, I and J

75
Q

What does long-term care help with

A

It provides custodial care by assisting in activities of daily living (ADLs)

76
Q

What does long-term care do

A

It helps fill in the gaps in coverage for long-term nursing care between Medicare and Medicare supplement policies

77
Q

How does the waiting period (elimination period) work for LTC insurance

A

You have to pay for a certain number of days before LTC insurance kicks in to begin to pay

78
Q

What type of days does LTC insurance use to count

A

They use service days and not calendar days

79
Q

Define service days

A

Days in which the insured actually receives care

80
Q

How does the calendar day waiting period work

A

It begins on the first day of LTC service and counts consecutive calendar days until the waiting period is satisfied

81
Q

In order for LTC insurance to apply, how many ADLs will a person need help with

A

At least 3

82
Q

Voluntary coverage is offered to active employees and who else?

A

Their spouses under a limited form of “guaranteed issue”

83
Q

How is employer-sponsored LTC insurance generally underwritten

A

It is usually individually underwritten

84
Q

When is Medigap guaranteed to be issued

A
  • Applicant is 65
  • Enrolls in both A & B
  • Applies for a Medigap policy within 6 months after enrolling in traditional Medicare
85
Q

Who can buy Long-term care policies

A

Anyone who is not eligible for Medicaid (they can not offer LTC to Medicaid eligible members)

86
Q

Does Medicare provide any LTC benefits

A

No, you have to buy LTC benefits

87
Q

Is SNF long-term care benefits

A

No

88
Q

Define assignment of benefits

A

Physician agrees to accept the Medicare-approved amount

89
Q

What is Medicare Advantage

A

Part C

90
Q

What is Medicare Supplement

A

Medigap

Disability Income Insurance (9 decks)

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