CH 11 Senior Health Products
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60 Terms
What is cost-sharing?
Sharing expenses between the insured and insurer through deductibles, copayments, and coinsurance.
What is an HMO?
Health Maintenance Organization; prepaid medical service plan focused on preventive care using contracted providers.
What is a formulary?
A list of prescription drugs covered by a prescription drug plan.
What is assignment?
Provider agrees to accept Medicare-approved amount as full payment.
What is durable medical equipment (DME)?
Medical equipment prescribed for home use, such as oxygen equipment or wheelchairs.
What is Medicare?
A federal health insurance program for seniors and certain disabled individuals.
Who administers Medicare?
Centers for Medicare & Medicaid Services (CMS).
What department oversees CMS?
U.S. Department of Health and Human Services.
What are the four parts of Medicare?
Part A Hospital, Part B Medical, Part C Medicare Advantage, Part D Prescription Drugs.
What is Original Medicare?
Medicare Parts A and B only.
Does Original Medicare usually cover prescription drugs?
No, prescription drugs generally require Part D.
Does Original Medicare require a primary care physician?
No.
Does Original Medicare require referrals to specialists?
No, if the specialist accepts Medicare.
How is Part A (Hospital) funded?
Payroll taxes (FICA).
How is Part B (Medical) funded?
Beneficiary premiums and federal government revenues.
How is Part C (Medicare Advantage) funded?
Medicare payments to private insurers.
How is Part D (Prescription Drugs) provided?
Private prescription drug plans approved by Medicare.
Who qualifies for Medicare based on age?
Individuals age 65 or older.
Who qualifies for Medicare regardless of age due to disability?
Those receiving Social Security Disability benefits for 2 years.
Who qualifies regardless of age due to kidney disease?
Individuals with ESRD.
What is ESRD?
End Stage Renal Disease requiring dialysis or transplant.
What condition qualifies immediately for Part A when disability begins?
ALS (Lou Gehrig’s disease).
What benefits does fully insured status provide?
Social Security retirement, premium-free Medicare Part A, and survivor benefits.
What is the Initial Enrollment Period (IEP)?
7 months surrounding age 65 eligibility.
When does IEP begin/end?
3 months before the month turning 65/3 months after
When is General Enrollment Period?
January 1 – March 31 annually.
Who uses General Enrollment Period?
Those who missed initial Part B enrollment.
What is the Part B late enrollment penalty?
10% increase for each full 12-month period delayed.
When is Medicare Annual Enrollment Period?
October 15 – December 7.
What is Special Enrollment Period (SEP)?
Enrollment period for those delayed due to employer coverage.
How long is SEP after employer coverage ends?
8 months
What does Medicare Part A cover?
Hospital inpatient care, skilled nursing, home health, hospice.
How is Part A usually obtained?
Premium-free if fully insured under Social Security.
What happens if someone has fewer than 40 quarters?
They may have to pay a Part A premium.
Does Part A cover physician charges?
No.
What does Part A inpatient coverage include?
Hospital room, meals, nursing, supplies, operating room, drugs, tests, etc.
Does Part A cover outpatient hospital care?
No. Part B covers outpatient care.
What does Part A cover days 1–60?
Approved costs after deductible.
What does Part A cover days 61–90?
Approved costs minus daily coinsurance.
What happens after day 150?
Medicare pays nothing.
How many skilled nursing facility days are covered?
Up to 100 days per benefit period.
What must happen before skilled nursing coverage?
3-day inpatient hospital stay.
Does Part A cover hospice and home health care?
Yes, if requirements are met
Who can enroll in Part B?
Anyone enrolled in Part A.
What does Part B cover?
Doctors, outpatient services, medical supplies, preventive care.
What percentage does Part B generally pay after deductible?
80%
Is there a Part B out-of-pocket maximum?
No
Does Part B cover doctor services and mental health?
Yes
What preventive visit does Part B cover?
Annual wellness visit
What is Medicare Advantage?
Private insurance alternative to Original Medicare.
What parts must a person have to enroll in Medicare Advantage?
Parts A and B
What organizations commonly provide Medicare Advantage?
HMOs and PPOs.
What extra benefits may Medicare Advantage offer?
Vision, hearing, dental, wellness programs, prescriptions.
What is a PFFS plan?
Private Fee-for-Service Medicare Advantage plan.
What is an SNP?
Special Needs Plan for specific populations.
Who qualifies for SNP?
Dual eligibles, nursing home residents, certain chronic conditions.
Must a person have Medicare to enroll in Part D?
Yes, Part A and/or Part B.
What is the Part D late penalty?
1% per month delayed (12% per year).
How many drugs must each treatment category include?
At least 2
What is creditable prescription coverage?
Coverage expected to pay at least as much as Medicare Part D.