Social Insurnace Flashcards
Medicare VS Medicaid VS Social Security (SSI)
Medicare- 65+ health insurance - payroll tax deductions federal insurance, end stage renal failure, ALS, dialysis - eligible for SSDI for 24 months
Medicaid- health insurance for the poor- state and federally funded ,
SSDI- benefits for disabled - income
Medicare- (4)
Part A - Hospital Insurance-
- automatic and mandatory 65+
- no additional premium
Part B - Medical Insurance (Doctor)
- Optional for additional premium
A+B = Traditional Medicare - Reimbursement Plan
Part C - “Medicare Advantage”
- Managed Care Plan (Ex HMO, PPO) - Private insurance carrier
- Networks
Part D - Prescription Drugs Plans (PDP)
Opt out of part A and B go to —> Part C which automatically comes with Part D (AKA MAPD)
Traditional Medicare
Part A (Hospital Insurance and Part B (Medical Insurance)
Medicare Participating and Non Participating
Participating - doc has agreed to accept medicare approved charge as “FULL Payment”
Non Participating - doc has not
Medicare example - Bill is $125 / Approved is $100 payment
*Participating Doctor- Medicare pays $80 - Patient”Beneficiary” pays remanding $20 and “eats the rest” - Doctor cannot “Excess bill” beneficiary
*Non Participating- Medicare pays $80 - Patient pays $20 and the “Excess Bill”
Medicare Supplement Plan
Is not medicare insurance- supplements the medicare policy to help pay some OR all of medicare expenses, deductibles, co-insurance, and co-pays
How much does Medicare pay for self administered prescription drugs?
$0
Part D of Medicare covers what?
Prescription Drug Plans
Hospital Insurance Covers what?
Inpatient Hospital Bills, In-patient skilled nursing, Home health care, hospice care (plan of teatment not a place),
What qualifies someone for Part A?
- Citizen or legal resident,
- 65+ entitled to monthly SS based on
- Under 65 and on SSDI for 24 months
- Under 65 and ALS or ESRD - dialysis
Part A Benefits
-Starts upon admission to hospital - 1st 60days 100%
- Next 30 days - CoPayment
- Next 60 (lifetime reserve) days - larger copayment
-Does not pay tv, tele, private nurses
— Ends when discharged for 60 consecutive days
150 days total benefit period
Benefit Period Deductible
Paid in first 60 days
After Benefits period part A how much does medicare pay?
Benefits period is 150 days and paid is $0
How long is Part A’s skilled nursing benefit covered for?
100 days per benefit period
- Days 1-20 paid at 100%
- Days 21-100 beneficiary pays portion per day
- Prereq- beneficiary had to be in hospital for at least 3 days in the last 30 days.
True or False - There can only be ONE primary beneficiary?
False- it is just an order of how many funds may be distributed in what order (succession)
What are owners rights?
Owner has all rights - name and change beneficiaries - if death benefit is part of contract - make any other changes without consent of the beneficiary
What about SSDI benefits before the 40 (quarters)?
ages 31-42 credits needed is 20 each year after requires additional credit. Age Credits needed 31-42 20 43 21 44 22 etc...
What is PIA?
Primary Insurance Amount - SSDI amount
To get SSDI benefits one must meet a strict definition. - what are the requirements?
Definition of Disability -
- Fully Insured (40 quarters over a lifetime)
- Disability Insured (20 of the last 40 quarters)
- Unable to perform ANY job exists in the national economy
- The disability must be in the type that will last at least 1 year or end in death
- 5 month waiting period
- Check in the 6th month and NOT retroactive
How much does Medicare pay towards Long Term Care?
$0
Medigap is what?
Medicare Supplement Policies - and only pays all or some of medicare deductibles, coinsurance, copays, provided from private insurance companies, standards are set by NAIC, NO medical requirements if beneficiary enrolls within 6 months of enrolling in Part B
Total Disability- Own Occupation Definition
unable to perform any of the duties of ones own occupation based on education training or experience
Total Disability - Any Occupation Definition
Unable to perform any of the duties of any occupation based on education training or experience
Partial Disability
a
Residual Disability
Not a type of disabiity but a method of dertermining
Recurrent - relapse
a
