Health Insurance for Senior Citizens and Special Needs Individuals

Attained age

the insured's age at the time the policy is issued or renewed

Benefit period

a period of time during which benefits are paid under the policy

Cost-sharing

sharing of expenses between the insured and the insurance company through deductibles, copays and coinsurance

Enrollee

a person enrolled in a health insurance plan, an insured (doesn't include dependents of the insured)

HMO

Health Maintenance Organization: a prepaid medical service plan in which specified medical service providers contract with the HMO and which focus on preventive care

Network provider

a provider who enters into a contractual arrangement with other providers to provide medical services to the network subscribers

Nonforfeiture benefit

a cash or insurance benefit received by a policyholder who no longer wishes to make payments after making premium payments for at least the minimum period

Outline of coverage

a document required in all health insurance policies that provides a full coverage disclosure to the applicant

Medicaid

Medical care for those whose income and resources are insufficient

Federal and state funded

Skilled care

daily nursing and rehabilitative care provided by medical personnel

Intermediate care

occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis than skilled nursing care

Custodial care

care for a person's activities of daily living provided in an institutional setting or in the patient's home

Home health care

provided by registered nurses, licensed practical nurses, licensed vocational nurses, or community-based organizations like hospice in one’s home

Residential Care

provided while the insured resides in a retirement community

Adult day care

provides for functionally impaired adults on less than a 24-hour basis

Respite Care

provides relief to the family caregiver; adult day care centers may also provide this type of relief

Assisted living

provides help with nonmedical daily activities

Part A Enrollment

Initial enrollment period - when an individual first becomes eligible for Medicare (starting 3 months before turning age 65, ending 3 months after the 65th birthday)

Part A Coverage

Inpatient Hospital Care
Skilled Nursing Facility Care
Home Health Care
Hospice Care

Part B Coverage (optional offered to everyone enrolled in part A)

Doctor Services
Outpatient Hospital Services
Home Health Visits
Other Medical and Health Services
Prescription Drugs (limited coverage)
Outpatient Treatment of Mental Illness
Yearly wellness visit

Part C

Medicare Advantage: requires enrollment in Parts A and B

Provided by an approved Health Maintenance Organization or Preferred Provider Organization

Part D

Prescription drug benefit

Optional coverage through private prescription plans that contract with Medicare

What are the activities of daily living?

Mobility, bathing, dressing, eating, toileting, and continence

How many pints of blood will be paid for by Medicare Supplement core benefits?

First 3 pints

In which Medicare supplemental policies are the core benefits found?

All plans (A-N)

What is another name for Medicare Advantage plans?

Part C

What part of Medicare is known as hospital insurance?

Part A

How is Part B Medicare funded?

By monthly premiums and from the general revenues of the federal government

How many parts does Medicare have?

Four: Parts A - D

What part of Medicare is known as medical insurance?

Part B

Can Alzheimer's disease be excluded from coverage under a long-term care policy?

No, organic cognitive disorders, such as Alzheimer's or Parkinson's must be covered

What Medicare part will cover lab services or diagnostic tests?

Part B

What is the purpose of respite care in long-term care insurance?

To provide relief for a major caregiver (usually a family member)

When is the initial enrollment period for Medicare Part A?

When an individual first becomes eligible for Medicare, starting 3 months before turning age 65 and ending 3 months after the 65th birthday

What is the required free-look period for Medicare Supplement policies?

30 days

Who qualifies for Medicare coverage?

People age 65 or older, or anyone who has been entitled to Social Security disability income benefits for 2 years, or who has chronic kidney disease

An insured with Medicare Part D has reached the initial benefit limit and must now pay a portion of prescription drugs costs. What is the term for this gap in coverage?

The donut hole

Who is eligible for Part B Medicare?

Part B is optional, and is offered to everyone who enrolls in Part A

What Medicare part provides a prescription drugs benefit?

Part D

What benefits are provided by Medicare Part C?

Expanded benefits for a fee through private insurance programs such as HMOs or PPOs.

Who issues Medigap policies?

Private insurers

If an individual is covered by Medicare, and is also covered by his employer's health plan, which plan would be considered primary?

The employer plan

At what age do individuals qualify for Medicare?

Age 65

What is the purpose of Medicare Supplement plans?

To fill in the gaps in Medicare coverage

What is another name for Medicare Supplement plans?

Medigap

What Medicare part helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care?

Part A

Medicare Part A will pay for what type of services?

Inpatient hospital care, skilled nursing facility care, home health care and hospice care

The annual Medicare open enrollment period is for

existing Medicare members who want to change their coverage

Which of the following persons is NOT eligible for Medicare?

A person who has been entitled to Social Security disability benefits for the last 6 months

Prior to purchasing a Medigap policy, a person must be enrolled in which of the following?

Parts A and B of Medicare

For at least how many consecutive months are long-term care policies required to provide coverage in Arizona?

24

Regarding the return of premium option for LTC policies, what happens to the premium if the policy lapses?

The insurer will return a percentage of the premiums paid

What option allows the insured to periodically increase benefit levels without providing evidence of insurability?

Guarantee of insurability

Which renewal provision(s) must be included in a long-term care policy issued to an individual?

Noncancellable and guaranteed renewable

Medicare Part A services do NOT include which of the following?

Outpatient Hospital Treatment

With regard to long-term care policies, which of the following is NOT considered an “activity of daily living”?

Walking

In which of the following locations would skilled care most likely be provided?

In an institutional setting

When is the annual Medicare open enrollment period?

October 15 – December 7

What is the amount a physician or supplier bills for a particular service or supply?

Actual charge

Which types of insurance companies marketing long-term care insurance coverage must establish procedures to assure that any comparison of policies by its agents will be fair and accurate?

Every company is required to establish marketing procedures

Prior to issuance of a Long-Term Care policy to an applicant age 80 or older, the insurer must obtain all of the following EXCEPT

Date of previous doctor visit

Which of the following is commonly provided in an institutional setting?

Skilled care