Senior Health Products

Question 1

Medicare Part A

Answer 1

Is hospital insurance and is financed through a portion of the payroll tax FICA.

Question 2

What is Medicare Part B and how is it financed?

Answer 2

Is medical insurance and is financed from monthly premiums paid by insureds and from the general revenues of the federal government

Question 3

What is Medicare Part C?

Answer 3

Also known as Medicare advantage allows people to receive all their health care services through available provider organizations

Question 4

Medicare Part D

Answer 4

Also know as Prescription drugs is for prescription drug coverage

Question 5

Original Medicare

Answer 5

Refers to Part A and Part B only.

Question 6

Medicare eligibility

Answer 6

Is for people 65 years or older even if they continue to work. They are also available to anyone, regardless of age, who has been entitled to social security disability income benefits for 2 years or has permanent kidney failure (ESRD)

Question 7

Initial enrollment period (IEP)

Answer 7

Is a 7 month period where an individual can enroll into Medicare part B. It begins 3 months before the month in which the person turns 65, the month they turn 65 and 3 months after their birthday month.

Question 8

General enrollment period

Answer 8

Runs from January 1st- March 31st of each year. If someone did not enroll in Medicare part B when they were first eligible they can do so during this time, but the cost of part B goes up 10% for each full 12-month period that the individual could have had part B but didn’t.

Question 9

When is a Special enrollment period (SEP) and who is eligible?

Answer 9

Is available to individuals who are eligible for Medicare part B, based on their age but waited to enroll because they had a group health plan through their own or spouses employer. They can sign up anytime while they’re still on the group health plan or during the 8 months following either termination of the group plan or employment.

Question 10

What does Part A cover?

Answer 10

Inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.

Question 11

Who is eligible for part A?

Answer 11

A citizen or legal resident of the US, who is age 65 or older and qualified for SS or railroad retirement benefits
-Is 65 years or older and entitled to monthly SS benefits based upon the spouses work record and the spouse is at least 62
-is younger than 65, but entitled to SS disability benefits for 24 months
-has End Stage Renal Disease
-has ALS

Question 12

What is the Cost and coverage for inpatient hospital care for Medigap part A?

Answer 12

Hospital insurance helps pay for up to 90 days in a participating hospital in any benefit period, subject to a deductible. The first 60 days are covered at 100% of approved charges after the deductible is met. The next 30 covered days are paid, but they’re paid with a daily copayment. There is a lifetime reserve of 60 days of hospital care. The reserve has a copayment that is twice that if days 61-90 and they are non renewable.

Question 13

What does Medicare Part A cover in regards to Skilled nursing facility care cost and coverage

Answer 13

Part A helps pay for up to 100 days in a participating skilled nursing facility in each benefit period, following a 3-day inpatient hospital stay for a related illness. The first 20 days are 100% paid for by medicare. Days 21-100 all is paid for by medicare except the deductible. Beyond 100 days the individual pays all the costs. The insureds doctor must certify that daily skilled care is necessary. Includes semi-private room, meals, regular nursing and rehabilitation services.

Question 14

Who is Home health care for what are the cost and coverage for Part A?

Answer 14

For an individual confined to the home and meeting certain conditions, hospital insurance can pay the full approved cost of home health visits from a participating home health agency. There is no limit to the number of covered visits. Includes part time skilled nursing care, physical therapy and speech therapy.

Question 15

Hospice care coverage and cost

Answer 15

Under certain conditions, hospital insurance can help pay for hospice care for terminally ill insured if the care is provided by a Medicare certified hospice. Includes doctor services, nursing service and medical appliances. Outpatient drugs.

Question 16

What does Medicare part B pay for?

Answer 16

For doctors services and a variety of the other medical services and supplies that are not covered by hospital insurance.

Question 17

Who is eligible for part B?

Answer 17

Part B is optional and offered to everyone who is enrolled in part A. Most people enrolled in part B pay the standard monthly premium. However if the insureds modified adjusted gross income reported on IRS tax return is above a certain amount, the insured may be required to pay a higher premium

Question 18

What is Medicare Part B cost and coverage?

Answer 18

After the annual medical insurance deductible is met, medical insurance will pay for 80% of the approved charges for covered expenses for the remainder of the year. There is no max out of pocket limit on the 20% coinsurance payable for part B expenses.

Question 19

Are Doctor services covered in part B?

Answer 19

They’re covered anywhere in the US, which include surgical services, diagnostic tests and X-rays

Question 20

In what settings are Outpatient hospital services covered in part B?

Answer 20

part b covers outpatient hospital services received for diagnosis and treatment such as care in an emergency room, outpatient clinic or a hospital

Question 21

What are coverages and cost for Home health visits under part B?

Answer 21

Medicare will pay for home health services as long as they’re recommended by the insureds doctor and the insured is eligible. They are on a part time basis with limits on the numbers of hours per day and days per week.

Question 22

What does Part B cover for Prescription drug coverage ?

Answer 22

Only medicines that are administered in a hospital outpatient department under certain circumstances such as injected drugs at a doctors office, some oral cancer drugs or drugs that require durable medical equipment are covered

Question 23

What Is Outpatient treatment of mental illness for part B coverage?

Answer 23

Medicare will cover outpatient treatment like depression or anxiety in a doctors office or other health care providers office or hospital outpatient department. 20% copay for the insured and part B deductible.

Question 24

Are Yearly wellness visits covered under part b?

Answer 24

Part b covers annual wellness visit during which the insured and the provider can discuss disease plan prevention. There is no out of pocket cost for these visits.

Question 25

What does Part C Medicare advantage cover?

Answer 25

Covers all of the services of original Medicare except hospice care. And some part c plans may have lower out of pocket costs and they also offer extra coverage like dental, vision and hearing.

Question 26

Who is eligible for part c?

Answer 26

You must also be enrolled in part a and b. Medicare advantage is provided by an approved HMO or PPO.

Question 27

What is the purpose of Medicare advantage special needs plans?

Answer 27

Provides more focused and specialized health care for specific groups of people. This includes people who have Medicare and Medicaid and who reside in a nursing home or have certain chronic medical conditions.

Question 28

What is Part D prescription drug coverage? And who is eligible?

Answer 28

This is optional coverage provided through private prescription drug plans that contract with Medicare. To receive this you must sign up with a plan offering this coverage in your area and be must enrolled in part a or in both a and b. There is a 1% penalty fee for anyone who doesn’t enroll when they’re first eligible per month they delay.

Question 29

How do Part D prescription drug premiums and deductibles work with coverage?

Answer 29

After the deductible is paid the plan would provide prescription drug costs coverage until a limit is reached. Once the beneficiary and their plan spend $4,660 combined on drugs(including deductible) the beneficiary will generally pay no more than 25% of the cost for prescription drugs until their out of pocket spending is $7,400 under the standard drug benefit.

Question 30

What is Part D catastrophic coverage?

Answer 30

Once the beneficiary has reached their out of pocket spending, catastrophic coverage begins automatically. It will cover 95% of prescription drug costs.

Question 31

Creditable coverage

Answer 31

Means health coverage that an individual had in the past that gives them certain rights when applying for new coverage like if they were a part of Medicare part a or b or Medicaid, under a state health benefit, under federal health employee benefit program.

Question 32

Medicare summary notice

Answer 32

Is a monthly statement that lists the insureds health insurance claims info, specific services covered and the amounts approved for each service

Question 33

What are Medicare supplement plans/Medigap?

Answer 33

Are policies issued by private insurance companies that are designed to fill in some of the gasps in Medicare. They help fill the gap in copay, deductibles and benefit periods. During open enrollment period coverage must be offered on a guaranteed issue basis.

Question 34

What is the OBRA ACT

Answer 34

It requires medigap plans to meet certain requirements as to participant eligibility and the benefits provided. And to eliminate questionable marketing practices and provide a level of protection to consumers.

Question 35

What does Medigap supplement Plan A cover?

Answer 35

The core benefits!
-Plan A coinsurance and copayment (not part A deductible)
-part a hospital costs up to an additional 365 days after Medicare benefits are used up
-part a hospice care coinsurance and copay
-part b coinsurance and copay
-the first 3 pints of blood

Question 36

What are the 2 benefits offered with Supplement Plan B?

Answer 36

In addition to the core benefits offered in Plan A, B also offers Medicare part A deductible

Question 37

What are the 4 benefits of Medigap Supplement Plan D?

Answer 37

Core benefits in A, part A deductible, skilled nursing facility coinsurance and the foreign travel benefit

Question 38

What are the 6 benefits covered in a Supplement plan G?

Answer 38

Core benefits, Medicare part a deductible, skilled nursing, 100% of Medicare part b excess charges, and foreign travel. Plus must pay for SERVICES OF ADL that Medicare doesn’t cover.

Question 39

Medicare supplement plans k and L

Answer 39

Have lower premium plans and higher out of pocket costs. Both have approved hospital costs for the copay for days 61-90 in any Medicare benefit period.
Both have approved hospital costs for copay for lifetime reserve days 91-150
Approved hospital costs for an additional 365 days after all Medicare benefits are used

Question 40

Supplement plan K

Answer 40

Includes 50% of the Medicare part A Deductible and 50% of skilled nursing coinsurance

Question 41

Supplement Plan L

Answer 41

Includes 75% of Medicare part a deductible and 75% of skilled nursing coinsurance

Question 42

All Medigap policies are guaranteed renewable, except for when?

Answer 42

Except for nonpayment of the premium or a material misrepresentation on the application

Question 43

Why do Medigap policies include a 30-day free look provision ?

Answer 43

It allows the insured to return the policy to the insurer within 30 days for a full refund of premiums paid.

Question 44

Medigap policies cannot include a provision that restricts coverage for what?

Answer 44

For pre-existing conditions for more than 6-months. If the person switching to a new Medigap policy after having another for at least 6 months, the new policy can’t have a waiting period for pre-existing conditions for the same coverage that was included in the old policy.

Question 45

What is a Medicare select policy?

Answer 45

Is a Medicare supplement policy that contains restricted network provisions. Provisions that condition the payment of benefits, in whole or in part, on the use of network providers.

Question 46

The Outline of coverage provided with Medicare supplement policies must be…

Answer 46

In the language and format prescribed by the CA insurance Code, be at least 12-point type, and include disclose that the policy may not cover all medical costs, for additional info contact HICAP, your local SS office or refer to the Medicare handbook and neither the company or agent are connected to Medicare

Question 47

The application for a supplement policy must include what?

Answer 47

Must include questions designed to elicit info as to whether or not as of the time of the application the applicant has current Medicare supplement, Medicare advantage, medi-cal coverage or another health insurance policy in force or whether the supplement policy is intended to replace any disability policy in force

Question 48

When does the Replacement Notice need to be provided?

Answer 48

Must be provided to the insured with the Medicare supplement policies offered in the replacement transaction. The notice must be prepared by the national association of insurance commissioners and be printed in no less than 12-point type

Question 49

What is Medi-Cal/Medicaid in CA

Answer 49

It is still largely funded with federal reimbursements. It’s free or low-cost coverage for adults and children with limited income and resources.

Question 50

Individuals who receive cash assistance from one of the following programs is automatically eligible for medi-cal.

Answer 50

-SSI/SSP(supplemental security income/state supplemental program)
-CalWORKS
-Refugee assistance
-foster care or adoption

Question 51

What are the Permitted commissions rules?

Answer 51

Agents may receive commissions as long as the 1st year commission does not exceed 200% of the commissions paid for selling or servicing the policy in the 2nd year.

Question 52

How long is Medigap open enrollment period?

Answer 52

A 6 month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare part B.

Question 53

What is an actual charge?

Answer 53

The amount a physician or supplier actually bills for a particular service or supply.

Question 54

What is an excess charge

Answer 54

The difference between the Medicare approved amount for a service or supply and the actual charge

Question 55

What is limiting charge

Answer 55

The max amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment

Question 56

What is an assignment in Medicare terms?

Answer 56

The physician or a medical supplier agrees to accept the Medicare approved amount as full payment for the covered services

Question 57

What is an approved amount?

Answer 57

The amount of Medicare determines to be reasonable for a service that is covered under Part B of Medicare.