Unit 20 Medicare and Medicaid

Question 1

Medicare eligibility

Answer 1

age 65 or over
have end-stage renal disease (kidney failure)
have been receiving Social Security benefits for at least 24 months

Question 2

Medicare part A enrollment

Answer 2

automatic for persons age 65 and eligible for social security
supported by payroll taxes
premium charge for those not fully qualified for social security

Question 3

Medicare part A hospital

Answer 3

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

Question 4

skilled nursing facility (SNF)

Answer 4

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

Question 5

home health care

Answer 5

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

Question 6

hospice

Answer 6

comfort care for terminally ill persons and their families
can be provided in the home or an approved facility

Question 7

Medicare part A exclusions

Answer 7

first three pints of blood
private duty nursing
non-medical services
intermediate care
custodial care

Question 8

Medicare part B

Answer 8

optional, can have Part A only
monthly premium that increases with income level

Question 9

Medicare part B initial enrollment period

Answer 9

3 months before age 65
month of age 65
3 months after age 65

Question 10

Medicare part B general enrollment period

Answer 10

January 1 - March 31 each year
coverage starts at the beginning of the following month after enrollment

Question 11

Medicare part B coverage and cost sharing

Answer 11

doctor
outpatient services
home health (if not covered by Part A)
calendar year deductible
80/20 coinsurance after deductible
no stop loss

Question 12

Medicare Part B exclusions

Answer 12

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

Question 13

Medicare part C - Advantage Plans

Answer 13

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

Question 14

4 types of Medicare Advantage plans

Answer 14

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

Question 15

Medicare Part D drug plan

Answer 15

purchased from a private company
Medicare pays the private company
private company pays the pharmacy
premium charge- reduced by income level

Question 16

coordination between Medicare and group health

Answer 16

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

Question 17

Medicare Supplement Plans (Medigap)

Answer 17

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

Question 18

Medigap regulations

Answer 18

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

Question 19

Medicare SELECT

Answer 19

similar to a managed care plan
restricted provider network

Question 20

Medicaid

Answer 20

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