chapter 17 notes: medicare

Question 1

medicare

Answer 1

provides hospital and medical expense insurance to individuals 65 and older or younger individuals with certain disabilities

Question 2

what does part A cover?

Answer 2

hospital insurance (room, nursing services, drugs, tests, etc)

does not include physician or surgeon charges

Question 3

what does part B cover?

Answer 3

supplementary medical insurance for physician visits, preventative care, and other outpatient care

Question 4

what does part C (medicare advantage) do?

Answer 4

offers managed care alternative to original medicare through government funding, like HMOs and PPOs

Question 5

what does part D cover?

Answer 5

prescription drugs

Question 6

original medicare vs medicare advantage (part C) coverage

Answer 6

original medicare: includes part A and B, which do not cover all costs, so many purchase Medigap to supplement it

part C: more comprehensive, as it incorporates part A and B benefits and addresses coverage gaps like vision, dental, and drug coverage

Question 7

who is eligible for medicare?

Answer 7

those who are entitled to social security benefits (they have worked 40 terms and paid medicare taxes for 10 years) and 65 or older or younger if they suffer from specific disabilities

Question 8

enrollment in part A

Answer 8

is automatic at 65 if they receive social security benefits

Question 9

enrollment in part B

Answer 9

individuals are offered to enroll in part B at age 65 and may suffer consequences if they do not enroll right away

Question 10

enrollment in part C and D

Answer 10

once enrolled in original medicare, one may enroll in part D or opt out of original medicare in favor of part C

Question 11

when does the special enrollment period apply for medicare part B?

Answer 11

when individuals are under a qualified COBRA health plan and still working past 65

Question 12

late enrollment penalty (part B)

Answer 12

10% penalty for each 12-month period a person could’ve been covered but chose not to be (unless covered by a group health plan)

Question 13

part A premiums

Answer 13

if they are “fully insured” (they have paid FICA taxes for 10 years), there are no monthly premiums

those who are not fully insured may still acquire part A by paying premiums

Question 14

part B premiums

Answer 14

all individuals pay a standard monthly premium that changes annually

premiums are reduced from their social security check

Question 15

part C premium

Answer 15

premiums are the same as the part B premium, sometimes with additional fees

Question 16

part D premium

Answer 16

if purchased with original medicare: premiums are unique to each plan

if under a medicare advantage plan: plan already offers part D for extra premiums

Question 17

participating providers

Answer 17

accept payments directly from medicare. they have agreed to accept the approved medicare fee as the full amount

Question 18

balance billing

Answer 18

participating providers cannot bill the patient for the balance between medicare’s reimbursement and the doctor’s usual charge

Question 19

nonparticipating providers

Answer 19

must collect their fees directly from the insured

insured is responsible for any amount over the medicare-approved amount

and insured must file a claim with medicare to be reimbursed for the cost

Question 20

medicare summary notice (MSN)

Answer 20

delivered every three months and provides a list of all services that providers have billed to medicare during the three month period

a summary, not a bill

Question 21

which part covers skilled nursing care benefits?

Answer 21

part A

Question 22

skilled nursing care coverage

Answer 22

medicare covers up to 100 days in a skilled nursing facility, where days 1-20 are paid in full and 21-100 require a co-pay

Question 23

custodial care

Answer 23

the nonmedical support to help individuals perform the basic activities of daily living

Question 24

does part A cover custodial care?

Answer 24

no

Question 25

what are other part A benefits?

Answer 25

inpatient psychiatric care (lifetime limit of 190 days), home health care benefits, hospice care

Question 26

part A inpatient hospital care

Answer 26

covers up to 90 days per benefit period if an insured re-enters the hospital less than 60 days after being released, it is a continuation of the same benefit period

Question 27

part A lifetime reserve days

Answer 27

a backstop to regular hospital benefits days that individuals can use when they spend more than 90 days per benefit period in the hospital

Question 28

part A cost sharing for inpatient hospital stays

Answer 28

a deductible is paid at the beginning of each benefit period first 60 days: no copayment last 30 days: daily coinsurance of 25% of the deductible lifetime reserve days: daily coinsurance of 50% of the deductible

Question 29

part A skilled nursing care cost sharing

Answer 29

no deductible is paid first 20 days: no copayment days 21-100: daily coinsurance of 12.5% of the deductible past 100 days: insured is fully responsible

Question 30

part A blood cost sharing

Answer 30

insured is responsible for the costs of the first three pints of blood

Question 31

part A hospice care cost sharing

Answer 31

must pay $5 for outpatient prescription drugs must pay 5% of the Medicare-approved amount for inpatient respite care

Question 32

what does part B cover

Answer 32

the essential health care services (lab work, diagnostic tests lab supplies), 100% of preventative services, and other costs not included in part A like the cost of surgeons and anesthesiologists

Question 33

part B premiums and cost sharing

Answer 33

monthly premium and an annual deductible, and both change annually after the insured meets the deductible, part B will pay 80% and insured will pay 20% coinsurance

Question 34

what is the out-of-pocket maximum for part B?

Answer 34

there is no out-of-pocket maximum for part B

Question 35

part B blood cost sharing

Answer 35

insured pays all costs for first three pints, then 20% coinsurance for more

Question 36

part C eligibility

Answer 36

must be enrolled in parts A and B, must not be suffering from kidney failure, and cannot be enrolled in Medigap

Question 37

types of part C plans

Answer 37

HMOs, PPOs, PFFS plans, SNP

Question 38

private fee-for-service (PFFS) plans

Answer 38

a plan under medicare part C where an individual may see any medicare-approved doctor or hospital that accepts medicare payments

Question 39

medicare advantage special needs plans (SNP)

Answer 39

focused health care for specific disabling (chronic) conditions in addition to standard health care services

Question 40

medicare part D eligibility

Answer 40

part C enrollees are ineligible must be enrolled in part A, B, or both permanently disabled and have been receiving SSDI benefits for at least 2 years those suffering kidney failure or from ALS

Question 41

part D enrollment and penalty

Answer 41

initial enrollment period is the same period for part B those who fail to enroll may be subject to a 1% lifetime premium penalty for each month without coverage

Question 42

part D benefits and cost sharing

Answer 42

after insured pays the deductible, they pay up to 25% of the medication costs there are maximum deductibles and out-of-pocket limits that change annually

Question 43

medicare supplements (Medigap)

Answer 43

sold by private insurers to fill in coverage gaps in medicare cover deductibles, coinsurance, and inpatient care when medicare benefits run out

Question 44

medigap eligibility

Answer 44

only available to those with parts A and B, and individuals can only have one medicare supplement

Question 45

variations of medigap plans

Answer 45

10 currently available plans: A-N some plans are no longer solg, but have plans that were grandfathered

Question 46

plan A medigap

Answer 46

the most basic medicare supplement plan and has the core benefits available in all medigap plans

Question 47

plan A medigap benefits

Answer 47

covers part A coinsurance and hospital costs up to an additional 365 lifetime reserve days after medicare benefits are exhausted covers the part B 20% coinsurance covers the first 3 pints of blood

Question 48

medigap loss ratio

Answer 48

law mandates that a certain amount of claims are paid out for premiums paid for individual medigap policies: 65% group plans: 75%

Question 49

medigap premiums (3 ways)

Answer 49

issue age attained age: premiums increase each year with one's age community rating

Question 50

medicare select

Answer 50

policies available to some areas that work like a closed-end HMO

Question 51

long term care insurance purpose

Answer 51

to indemnify individuals for the highest quality of life possible different than medicare and medigap, as those focus on recovery

Question 52

formal vs informal care in long term care insurance

Answer 52

formal: provided by professional workers informal: provided by family members (not covered by insurance)

Question 53

continuing care communities

Answer 53

allows individuals to access progressively more intensive levels of care without leaving the community

Question 54

respite care

Answer 54

offers the primary, informal caregiver with time off from providing care

Question 55

long term care insurance benefit periods

Answer 55

minimum is 1 year, maximum is lifetime average nursing home stay is 2.5 years, so many choose 3

Question 56

pool of money concept

Answer 56

a method used by insurers to determine daily benefits in long-term care insurance benefits are limited by the number of available dollars rather than the number of days example: longer benefits will be paid for home care as opposed to a nursing facility because it is cheaper

Question 57

how much does medicare part B cover for most doctor's services, outpatient treatments, and durable medical equipment?

Answer 57

80%

Question 58

how long does Medicare Part A provide benefits for days in a skilled nursing facility?

Answer 58

100 days