Unit 20 Medicare and Medicaid Flashcards
Medicare eligibility
age 65 or over
have end-stage renal disease (kidney failure)
have been receiving Social Security benefits for at least 24 months
Medicare part A enrollment
automatic for persons age 65 and eligible for social security
supported by payroll taxes
premium charge for those not fully qualified for social security
Medicare part A hospital
90 days per benefit period
new benefit period starts 60 days after discharge
additional 60 lifetime reserve days
deductible per benefit period (after the deductible, Medicare pays 100% of the first 60 days)
patient pays a copay per day for days 61-90
patient pays a higher daily copay for lifetime reserve days
skilled nursing facility (SNF)
medical treatment
following a hospital stay of at least three days
100 days of coverage. days 1-20 are 100% paid by Medicare, days 21-100 has a daily copay paid by the patient
home health care
skilled care provided in the home (part-time nursing care for PT, OT, or speech therapy)
not sitting services
100% paid by Medicare
Medicare pays 80% of DME in the home
hospice
comfort care for terminally ill persons and their families
can be provided in the home or an approved facility
Medicare part A exclusions
first three pints of blood
private duty nursing
non-medical services
intermediate care
custodial care
Medicare part B
optional, can have Part A only
monthly premium that increases with income level
Medicare part B initial enrollment period
3 months before age 65
month of age 65
3 months after age 65
Medicare part B general enrollment period
January 1 - March 31 each year
coverage starts at the beginning of the following month after enrollment
Medicare part B coverage and cost sharing
doctor
outpatient services
home health (if not covered by Part A)
calendar year deductible
80/20 coinsurance after deductible
no stop loss
Medicare Part B exclusions
routine physical exams beyond the initial exam within 6 months of coverage
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 for accidental injury)
most care received outside the US
expenses incurred as a result of war
Medicare part C - Advantage Plans
Medicare contracts with and pays private companies
enrollee’s medical expenses are paid by the private plan
enrollee must be enrolled in Medicare Parts A & B
private company may charge the enrollee a fee
may provide outpatient drug coverage
4 types of Medicare Advantage plans
Medicare managed care plans
-HMO or POS
-gatekeeper
-care must be obtained from the plan’s network of providers
-enrollees may have to pay a copay per doctor visit
PPO
-no gatekeeper
-more cost if outside of network
Private fee-for-service (PFFS) plan
-plan negotiates the fees that providers will be paid
Medicare specialty plans
-special needs such as kidney failure
Medicare Part D drug plan
purchased from a private company
Medicare pays the private company
private company pays the pharmacy
premium charge- reduced by income level
coordination between Medicare and group health
employers with fewer than 20 employees, Medicare is primary
employer with 20+ employees, group plan is primary for employees and Medicare is primary for retirees
Medicare Supplement Plans (Medigap)
private insurance plan
premiums are not subsidized by Medicare
cannot be sold to an enrollee in a Medicare Advantage plan
Plan A provides core benefits only
-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 Medicare part B coinsurance
-must be offered if the company sells any Medicare supplement plans
-doesn’t cover Part A & B deductibles
Medigap regulations
must be given an NAIC buyer’s guide
30-day free look
guaranteed renewal
guaranteed acceptance if bought within six months of enrollment in Medicare 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 commissions cannot be greater than the new policies renewal commission
if allowed, preexisting conditions cannot be excluded for more than six months
Medicare SELECT
similar to a managed care plan
restricted provider network
Medicaid
health coverage for the poor
regardless of age
a person can be covered by Medicare and Medicaid
funded by state and federal government
managed by the state
