Unit 20 Flashcards
Department responsible for managing Medicare and Medicaid
Centers for Medicaid and Medicaid Services
What are the requirements to qualify for Medicare
65+, end stage renal disease, been receiving social security disability for over 24 mo, must be fully insured by social security
What does being fully insured require
40 credits
What are private companies that process Medicare know as
Medicare Administration Contractors
How long is the Initial enrollment period for medicare and when does it start
7 mo, 3 mo before the month they turn 65
What are the 4 parts of medicare
Part a,b,c,d
What does Part A cover
Hospital stays and costs related
What does Part B cover
Doctor’s fees and medical services
What does Part C cover
Care delivered by Managed Care plans
What does Part D cover
Prescriptions
How do you enroll for Original Medicare
It’s automatic
What is Original Medicare
Part A and B
What is a Part A benefit period
Starts when admitted to a hospital and continues 60 days after discharge, if readmitted within the 60 days the period continues
How many lifetime days does a beneficiary of Part A receive and what is the daily copay rate
60, 200% of days 61-90
What is a SNF
Skilled Nursing Facility
When does a stay at a SNF need to begin in order for it to be covered by Medicare
Immediately after a hospital stay of at least 3 days
How long can you stay at a SNF and Medicare pay for it
100 days
How many pints of blood is excluded from Part A coverage
First 3
How do you enroll in Part B
It’s automatic with enrollment in Part A
What is the Benefit period for Part B
Calendar year
What are the 3 types of services Part B covers
In/out patient physician services, home healthcare, out patient medical services/supplies
What is the rate for coinsurance for Part B
20%
What is it called when a physician agrees to pay what Medicare determines a reasonable charge
Assignment
When were Part A and B signed in
1965
What type of payment does Original Medicare operate on
Fee-for-service
When was Part C enacted
1990s
What is Part C commonly referred to as
Medicare Advantage
What does a Medicare Advantage plan do
Provides with Part A and B benefits as well as additional benefits
What are the types of Advantage Plans
Medicare Managed Care plan, Medicare Preferred Provider organization plan (PPO), Medicare Private Fee-for-service, Medicare Specialty Plans
Operate like an HMO, care must be obtained in network and with a primary gatekeeper. Pays a copay per visit with no deduct/coinsurance. Covers more preventative care. Advantage Plan
Medicare Managed Care Plan
Advantage plan that acts like a PPO
Medicare Preferred Provider Organization Plan
Operates like original medicare but negotiates fees from providers
Medicare Private Fee-for-service (PFFS) Plan
Advantage plan focusing on the particular needs of a defined group
Medicare Specialty Plan
What was the coverage gap when Part D was implemented called
Donut Hole
The inflation reduction act of 2022 did what to the donut hole
Eliminated it
What was the efficacy date of the annual spending threshold for the max out of pocket limit for Part D
Jan 1st 2024
What Parts of Medicare are run by the government
Part A and B
What parts of Medicare are run privately
Part C and D
What is Medigap
Medicare Supplement Insurance
Who standardized Medigap
National Association of Insurance Commissioners (NAIC) and Center or Medicaid and Medicaid services (CMS)
How many Medigap plans are there
10
Who regulates the sales and offerings of Medigaps
States
What is the purpose of Medigap
To fill gaps in Original Medicare
If insurers offer Medigap what policy are they required to offer
Plan A
What is different about Medigap Plan K and L
Lower premium and higher out of pockets
Who is eligible to sign up for Medigap plans C,F, and high deductible F
Applicant first eligible for medicare after 2020
What must be given to all applicants for a Medigap plan
A buyer’s guide and an Outline of coverage
When must insurers guarantee issue of a Medigap plan
Applicant is 65+ and enrolled in Part B in the last 6 months
What is the renewability of a Medigap plan
At least Guaranteed Renewable
How long can Pre-existing conditions be excluded from coverage in a Medigap plan
6 months
What is Medicare SELECT
Coverage offered through a restricted provider network
Who qualifies for Medicaid
The poor
