Chapter 10: Medicare

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. What is the current monthly Part B premium?

$135.50, with a higher premium if one was eligible to enroll but did not do so.

How much is the deductible for the standard Prescription Drug Benefit plan?

$435 in addition to a monthly premium.

For skilled nursing facility care, what does Part A cover?

Semi-private room, meals, skilled nursing and rehab services, and other services and supplies (after a related 3-day hospital stay.)

Where is the monthly premium for Part B deducted from?

Social Security, Railroad Retirement, or Civil Service Retirement checks.

What is a deductible as it pertains to Medicare?

The amount one must pay each year before Medicare begins paying its portion of the medical bill. The deductible is taken out of one's claims when Medicare receives them. Medicare will not start paying on a patient's claims until he/she has met annual deductible.

What is an assignment?

The transfer of a legal right or interest to an insurance policy.

What is the Medicare Advantage Plan?

They offer drug coverage that can either be added or is already part of the plan. If drug coverage is part of the plan, enrollment in another prescription plan is prohibited and the person will be dropped from the Medicare Advantage Plan and returned to the Medicare Plan.

What happens after deductible is satisfied?

Typically, Medicare pays a portion of the approved charges.

When you become eligible for Part A, you will get and have to pay for Part B unless you decline it. If you later decide you want part B after initially declining it, when can you sign up for it?

You must wait until the next general enrollment period.

What is Part A of Medicare?

hospital insurance, is financed through a portion of the payroll tax (FICA)

What are Medicare coverage exclusions?

Acupuncture, deductibles/coinsurance/copayments, dental care/dentures, cosmetic surgery, custodial care at home or in nursing home, health care received when traveling outside US, hearing aids/exams, immunizations (except flu/pneumonia), orthopedic shoes, outpatient prescription drugs, routine foot care, routine eye care and most eyeglasses, routine or yearly physical exams, screening tests, and 1st 3 pints of blood received during one calendar year.

Who is Medicare available to?

Generally, people aged 65 or older, younger people with disabilities (someone who has been entitled to Social Security disability income benefits for at least 2 years), and people with end-stage renal disease (permanent kidney failure requiring dialysis or transplant).

With Medicare Part C, the enrollee receives the benefits of both Parts A and B and usually the extra benefit of prescription drug coverage as found in Part D. What are the available types of plans?

HMOs, PPOs, Private fee-for-service (PFFS), and Special needs plans (SNP).

If your client is younger than 65, he or she can get Part A without having to pay premiums if they:

Have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months; or is a dialysis or kidney transplant patient (has end-stage renal disease - ESRD)

What does Part A cover?

Helps cover one's inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. Also covers hospice care and some home health care.

What is Part B of Medicare?

medical insurance, is financed from monthly premiums paid by insureds and from the general revenues of the federal government

For Part B, what does outpatient hospital services include?

Hospital services and supplies received as an outpatient as part of a doc's care.

While the HMO, PPO, PFFS, and SNP plans are similar to the private health insurance network, what is a stipulation?

Medicare program must approve the provider and there are other features that must be present.

What happens if your client does not receive checks from Social Security, Railroad Retirement, or Civil Service Retirement, and thus Part B premiums cannot be deducted from them?

Medicare sends client a bill for the Part B premium every 3 months. If a person is eligible for Part B before a Social Security benefit check is due, a quarterly invoice will be issued.

The Medicare Advantage Plan was previously called Medicare+Choice. What is Part of Medicare is this?

Part C. It is a product of the Balanced Budget Act of 1997. Effort by the government to offer the consumer more choices under Medicare by bringing in privately managed care providers and fee-for-service plans as options.

A membership card is issued upon enrollment and it's difficult to get a prescription filled without a membership card. What should the client do while waiting for their card?

Request a letter from the insurance company to present to the pharmacy stating that drug coverage is effective, the date, and all membership info.

What is the one plan that must provide prescription drug coverage?

SNP

What is Part D of Medicare?

prescription drug coverage

For hospital stays, what does Part A cover?

semi-private room, meals, general nursing, and other hospital services and supplies. Includes the care received in critical access hospitals and inpatient mental health care.

What is the Medicare Prescription Drug Plan (PDP)?

simply add the coverage to a person's Medicare program or one of the plans such as PFFS or a Medical Savings Account (MSA).

What specific drugs are excluded from Part D?

weight loss/gain/anorexia drugs, fertility drugs, cosmetic or hair growth drugs, erectile dysfunction drugs, vitamins/minerals, cough/cold drugs, nonprescription drugs.

What were the Medicare deductibles for 2019?

Part A for each benefit period was $1364 and Part B was $185/year. Amounts typically change each year for inflation.

For hospital stays, how many days will Medicare cover at 100% for approved services?

60 days.

For Part B, Medicare pays for medical services in or out of the hospital. How much do they pay? How much does patient pay?

80% approved amount after the deductible. Patient pays deductible + 20% of approved amount and limited charges above approved amount.

What is Medigap?

A Medicare supplement policy.

What is the "donut hole"?

A coverage gap which begins after the beneficiary and the drug plan have spent a certain amount for covered drugs ($4020 in 2020). In coverage gap, beneficiary is responsible for 25% of brand name prescription drug costs and 25% of the plan's cost for covered generic drugs.

What does the recipient receive under Part C?

Care for both Part A (hospital insurance) and Part B (medical insurance). Coverage is rolled into one plan provided by a Medicare-approved insurance company.

What is respite care?

Care given to a hospice patient by another caregiver so that the usual caregiver can rest.

In Part D, what happens once the beneficiary has met the plan's out-of-pocket cost req's for the year? ($6350 for 2020)

Catastrophic coverage begins automatically which will cover 95% of prescription drug costs. The beneficiary pays the greater of $3.60 for generic drugs and $8.95 for name brand, or 5% of retail cost, whichever is higher.

Who is Medicare administered by?

Center for Medicare and Medicaid Services, which is a division of the US Department of Health and Human Services.

If an insurer's clients (or the client's spouses) did not pay Medicare taxes while they worked, but are 65 or older and are citizens/perm residents of the US, are they able to buy Part A?

Maybe

What does Part B cover?

Medical and other services, clinical lab services, home health care, outpatient hospital services, blood, and yearly "wellness" visit

For hospice care, what does Part A cover?

Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. While hospice is given in person's home, short-term hospital and inpatient respite care are covered when needed.

The prescription drug program is available to all Medicare recipients regardless of their enrollment program. Part D is available through private insurance companies that have been approved by Medicare. What are the 2 types of plans?

Medicare Prescription Drug Plans (PDPs) and Medicare Advantage Plans (HMOs or PPOs)

After 60 days in the hospital covered at 100%, what is the payment arrangement for the next 30 days?

Medicare covers all approved services, except the daily deductible.

For Part A, the deductible is applicable for each benefit period based on the hospital stay. How long are the benefit periods?

1 to 60 days and based on coinsurance amounts after 60 days.

What additional coverages does Medicare help cover?

Ambulance (when medically necessary), artificial eyes, artificial limbs that are prosthetic devices/replacement parts, braces (arm, leg, back, neck), chiropractic services (limited), emergency care, eyeglasses, immunosuppressive drug therapy for transplant that was paid for by Medicare, kidney dialysis, macular degeneration (age-related) treatment, medical nutrition therapy services for people with diabetes/kidney disease w/ dr. referral, outpatient prescription drugs, preventive services, 2nd opinion by a dr., services of clinical social workers/physician assistants/nurse practitioners, telemedicine services in rural areas, therapeutic shoes, transplants, and x-rays/MRIs/CT scans/EKGs and some other diagnostic tests.

Individuals can get Part A at 65 without having to pay premiums if they meet the following req's:

Are receiving retirement benefits from Social Security or the Railroad Retirement Board; are eligible to receive Social Security or railroad benefits, but have not yet filed for them; or had Medicare-covered government employment.

For Part B, what does clinical lab services cover?

Blood tests, urinalysis, and more.

While I understand HMO and PPO, how does the Private fee-for-service (PFFS) work?

Different by being offered by a private insurance carrier. Medicare pays the carrier a flat amount each month to provide coverage for the participant. The PFFS plan then contracts with a network of physicians and facilities to provide medical care to the participants.

For Part B, what does medical and other services include?

Doctors' services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (wheelchairs, hospital beds, oxygen, and walkers), 2nd surgical opinions, outpatient mental health care, outpatient physical and occupational therapy, including speech-language therapy.

While an individual becomes eligible for Medicare at 65, federal laws extend primary coverage benefits under the employer's plan to active older employees regardless of age. How does this relate to primary and secondary coverage?

Employer plan continues to be primary coverage and Medicare is secondary coverage.

For Part B, what is the yearly "wellness" visit?

In addition to a "welcome to Medicare" preventive visit available during the 1st 12 months, Medicare Part B covers annual "wellness" visit during which the insured and the provider can develop or update a personalized plan for disease prevention.

What is "step therapy"

In some cases, the carrier will insist that a similar drug that costs less be tried and the benefits analyzed before a more expensive drug is authorized.

When is the general enrollment period?

January 1 - March 31

Part D enrollment is the same as the initial enrollment period, with late enrollment during the annual enrollment period. What happens with late enrollments?

Late enrollment penalty for those who did not join when 1st eligible and did not have prescription drug coverage during that time or for more than 63 continuous days.

What must Medicare Advantage plans offer?

Must offer all services from Part A and B, except hospice care, but emergency care is always provided.

Are OTC drugs included in Plan D?

No.

Which Parts of Medicare have deductibles?

Part A (hospital insurance) and Part B (medical insurance)

For home health care, what does Part A cover?

Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (wheelchairs, hospital beds, oxygen, walkers), medical supplies, and other services.

For Part B, what does home health care include?

Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment and medical supplies, and more.

What are the 4 distinct Parts of Medicare?

Parts A, B, C, D

If hospital stay is longer than 90 days, who is responsible for the charges?

Patient is responsible for 100% of the charges after 90 days.

Regarding blood, what does Part A cover?

Pints of blood a patient gets at a hospital or skilled nursing facility during a covered stay.

For Part B, what does blood service is included?

Pints of blood a patient receives as an outpatient or as part of a Part B covered service.

For hospital stays, what does Part A not include?

Private-duty nursing, a television, or a telephone in the room. Does not include a private room unless medically necessary.

Drug plans charge a monthly fee that is not a set amount and will vary among the plans. Some plans may require enrollees to use a pharmacy within a network? Is there a deductible?

Yes, a yearly deductible applies.

Do high income earners have to pay more for Part B premiums?

Yes.

In Part D, can insurance companies require proof that the drug is medically necessary?

Yes.

In Part D, is there a limit on how much medication you can receive at one time?

Yes.

What is Part C of Medicare?

allows people to receive all of their health care services through available provider organizations