Medicare and Medicaid

What are the most common reasons someone qualifies for Medicare

Age 65.

End stage renal disease.

Have been receiving social security disability benefits for 24 months.

Lou Gehrig's disease

When is the initial enrollment period for Medicare

A 7th month period that begins 3 months before the month. Someone turns 65 and ends 3 months after the month they turn 65

How many parts are there in Medicare

Four

Medicare part A covers

Hospital skilled nursing, hospice and home Care

Medicare part b covers

Medical Care provided by physicians and other medical services

Medicare part c covers

Healthcare delivered by managed plans

Medicare part D covers

Prescription drugs

Which Medicare part are you covered under automatically at age 65

Medicare part A

Which Medicare part is called Medicare advantage

Part c

Which Medicare part was made law in 2006

Part D

Which Medicare part is always going to have a premium

Medicare part b

When does coverage with Medicare part A begin and how much does it cost

Automatic enrollment on the first day of the month you turn 65 and is free

Which two parts of Medicare are known as original Medicare

Part A and part b

What is the blood deductible

The total combined deductible of the first three pints of blood being at insureds 's own cost

Under part A inpatient hospital coverage is based on benefit periods rather than calendar year. How long is the benefit period

90 days

With a 90-day benefit period what days are fully covered by Medicare after the deductible

Days 1-60 are covered fully by Medicare days. 61. -90. The patient pays daily copay amount

What is a skilled nursing facility covered under Medicare part A

A facility for people who need round-the-clock medical Care provided by licensed nurses that is not a hospital

What are the conditions for a skilled nursing facility to be covered under Medicare part A

An approved facility, with a stay that begins immediately after release from the hospital of at least 3 days

What are the cost sharing amounts for a skilled nursing facility under Medicare part A

Day 1-20 fully paid by Medicare.

Day 21 -100 patient daily copay amount

Anything after 100 days not covered

If a patient is confined at home, Medicare part A offers, what covered benefit

Home health Care

What benefits are offered under Medicare part A's home health Care

Visits by home health aid to provide medical services, 80% of the cost of durable medical equipment such as hospital beds or wheelchairs

Comfort Care for terminally ill patients and family that can be provided in the home or in an approved facility covered under Medicare. Part A is called

Hospice Care

What qualifies someone for hospice care

If they are terminal with 6 months or less to live

What is the cost for prescription drugs during hospice care

$5 or 5%

What are exclusions from Medicare part A

First three pints of blood.

Private duty nursing

Non-medical services

Intermediate Care

Custodial care- help with daily activities living long-term

What is the general enrollment period For Medicare part b if someone declined coverage when they became eligible for part A

January 1st through March 31st with coverage starting the beginning of the following month

Since a premium is required to be paid out of your social security benefit check for Medicare part b enrollment is

Voluntary and optional

If a person declines to enroll when first eligible for Medicare part b, what must they do to become eligible to enroll later

Pay a penalty

In order to have a Medicare supplement policy you must have

Medicare part b first

What does Medicare part b cover

General kinds of medical services like inpatient and outpatient physicians, home health Care. (Not covered by part A) And outpatient medical services and supplies

What preventative care is included under part b

Initial routine physical within the first 6 months after enrollment.

Screening tests.

Mammograms, pap smears, pelvic exams

Prostate cancer screening age 50 or older

Glaucoma testing every 12 months

Bone mass measurements

Flu shots

What are the cost sharing rules for Medicare part b

A calendar year deductible that changes yearly, 20% coinsurance. Any part of the three-point blood deductible that has not been met under part A must be met under part b

No stop loss

What is the claims process for Medicare part b

Medicare determines reasonable charge for a service, patient pays the difference. If Medicare decides and expenses medically unnecessary, the patient must pay full cost

What is an assignment under Medicare part b

An assignment is the predetermined cost of a service by Medicare. A doctor can choose to accept the assignment, which means they cannot legally Bill the patient for anything more than that amount

What are common exclusions under Medicare part b

Routine foot, vision, dental or hearing Care.

Most immunizations.

Most outpatient prescription drugs.

Private duty nursing

Cosmetic surgery

Care received outside of the US

Act of war

Charges over assignment amount

Both Medicare part A and b operate on a

Fee for service basis

A Medicare advantage plan or Medicare managed plan is also called

Medicare part c

In order to enroll in Medicare part c you must

Have enrollments in part A and part b, pay the part b premium, the part c premium

What are the four types of Medicare advantage plans

Medicare managed Care.

Medicare PPO plans.

Medicare private fee for service plans.

Medicare specialty plans

What is Medicare part c

When private companies contract with Medicare to provide participants with part A and part b coverage with additional benefits at an additional cost

A Medicare managed plan operates much like what other type of health insurance policy

An HMO.

A Medicare specialty plan focuses on the particular needs of who

Defined groups of patients. Example those with certain medical conditions like kidney failure

In order to have Medicare part D coverage you must also have

Medicare part A and b

What are the costs associated with Medicare prescription drug coverage or part D

A monthly premium, an annual deductible with a maximum amount, 25% coinsurance until maximum out of pocket

If an individual under Medicare part D has entered the catastrophic coverage phase this means

They have reached their annual maximum out of pocket limit and will have zero out of pocket costs for the remainder of the calendar year

If an individual over 65 has Medicare and employer group health coverage, how is primary determined

If the employer has less than 20 employees, Medicare is primary, if more than 20 employees then Medicare is secondary

If an individual under age 65 who is on Medicare because of a disability and also has an employer group health plan, which coverage is considered primary

The employer plan would be primary. If the employer health plan covers at least 100 employees. Anything less Medicare would be primary

What is medigap

Medicare supplement insurance

If you have a medigap plan you cannot have

A Medicare advantage plan or Medicare part c

Who has standardized Medicare supplement plans

The national association of insurance commissioners( naic) and centers for Medicare and Medicaid services. (CMS)

How many standard medigap plans are there

10

All standard medigap plans must include certain basic or core benefits. What are these

100% of part A coinsurance plus the full cost of 365 days. After all part, a hospital benefits are exhausted.

Part b coinsurance or co-payment after deductible is met

The cost of the first three pints of blood each year

A plan A Medicare supplement covers what

ONLY Basic benefits. all insurers must offer plan a.

Which two Medicare supplement plans are different from all other plants offered

Plan k. K and plan L

Besides plan A, K, and L. All other medigap plans include various combinations of other benefits, in addition to what

Basic benefits

What must be given to all applicants for Medicare supplement policies at the time of application or upon delivery of a policy

A buyer's guide

The first page of a Medigap policy must contain

The words notice to buyer- this policy may not cover all medical expenses.

Prominent notice of the 30-day free look period

The policies renewal provision including any premium increase that may be involved

During the open enrollment. Insurers must guarantee the medigap policy if

The applicant is both 65 or older and has enrolled in Medicare part b in the last 6 months

Pre-Existing conditions for medigap policies can be excluded for the first 6 months of coverage but only if

The condition was treated in the 6 months immediately proceeding the effective date of the policy

What are the required provisions for a medigap policy

Must be at least guaranteed renewable.

Must be automatically adjusted for changes in Medicare.

May not duplicate benefits provided by Medicare

30-day free look

Pre-existing limitations may not last longer than 6 months from date of issue

What is the maximum sales commission that can be made on a medigap policy

No more than 200% of the renewal commission

If a medigap policy is replaced, the applicant must

Sign a notice be given a refund of unearned premium on the replaced policy and a credit under the new policy

Renewal commissions for medigap policies must level in

Years 2-5

What is Medicare select

Offered through a restricted provider Network, policyholder must have the option to switch to a medigap policy without restricted provider Network if wanted

To receive Medicaid a person must qualify for

Temporary assistance for needy families- generally called welfare, or supplemental security income( SSI)Temporary assistance for needy families- generally called welfare, or supplemental security income( SSI)

Medicaid is

State-Based, income based, for the medically needy at any age, can be used with Medicare

How is Medicaid funded

By state and federal government