Unit 20: Medicare Flashcards
eligibility
any of the following:
- age 65 and over
- kidney failure (end stage renal disease
- received social security disability for at least 24 months
Medicare Part A Enrollement
automatic form persons age 65 and eligible for social security
supported by payroll taxes
premium charge for those not fully qualified for social security
Part A
- 90day benefit period
- new benefit period starts 60 days after discharge
- additional 60 lifetime reserve days
- deductible per benefit period-after deductible Medicare pays 100% of first 60 days
- patient pays co-pay per day for days 61-90
- patient pays a higher daily co-pay for lifetime reserve days
Skilled nursing facility
around the clock care 24/7 (intermediate care/custodial care NOT covered by Medicare)
following a hospital stay of at least 3 days
100 days of coverage
- day 1-20 100% paid by Medicare
- day 21-100 daily copay paid by patient
home health care
skilled care provided in home
100% paid by Medicare
Medicare pays 80% of durable medical equipment in the home
Part A Exclusions
- first three pints of blood
- private duty nursing
- non-medical services
- intermediate care
- custodial care
Part B
monthly premium that increases with income level
not required
initial enrollment period (3 month before age 65, age 65, 3 months after age 65)
annual open enrollment January 1st-March 31st every year
coverage effective July 1
coverage and cost sharing
coverage: doctor, outpatient services (tests, etc.), home health (if not covered by part a)
calendar year deductible
80/20 coinsurance after deductible
no stop loss
Part B Exclusions
- routine physical exams beyond the initial one described
- routine foot, vision, dental, or hearing care
- most immunizations
- most outpatient prescription drugs
- physician charges above Medicare’s approved amount
- private duty nursing
- cosmetic surgery (unless accidental injury)
- most care outside of USA
- expenses incurred as a result of war or act of war
Part C
- Medicare contracts with and pays private companies
- enrollees medical expenses paid by the private plan
- must be enrolled in A & B
- private company may charge the enrollee a fee
- may provide outpatient drug coverage
Types of Part C Plans
Medicare managed care plans:
- HMO or POS
- gatekeeper
- care must be obtained from the plan’s network of providers
- enrollees may have a pay a co-payment per doctor visit
PPO
- no gatekeeper
- more cost if outside of network
Private fee-for-service (PFFS)
-plan negotiates the fees that providers will be paid
Medicare specialty plans
-special needs such as kidney failure
Part D
- purchased from a private company
- Medicare pays the private company
- private company pays the drug store
- premium charge-reduced by income level
- annual deductible
- 25% coinsurance
Coordination between Medicare and Group Health
- individual’s age
- employer size
- employment status (employee or retired)
- employers with less than 20 employees=Medicare is primary
- employers with 20+ employees= group plan is primary for employees and Medicare is primary for retirees
- Medicare eligible individuals under age 65 = group plan is primary if a large group plan
Supplement Plans (Medigap)
10 standard plans
can help pay copayments, coinsurance, deductibles
-private insurance plan
-premium not subsidized by Medicare
-Cannot be sold to an enrollee in a Medicare Advantage plan
-Core benefit Plan A
+must cover hospital copays for days 61-90 and lifetime days
+adds an additional 365 days of coverage to a benefit period-covered at 100%
+covers Part B coinsurance
+must be offered if company sells any supplement plans
+doesn’t cover Part A & B deductibles
Medigap Regulations
30 day free look
- must be given an NAIC buyers guide
- guaranteed renewal
- guaranteed acceptance if bought within six months of enrollment in Part B
- cold lead advertising not allowed
- sales commissions cannot exceed 200% of renewal commissions
- renewal commissions must be level in years 2-5
- replacement sales commission cannot be great than the new policies renewal commission
- if allowed, preexisting conditions cannot be exclude for more that six months
