CHAPTER 8

claims with part b

After an annual deductible ($183 in 2018) Part B will pay 80% of allowable charges for covered services for the remainder of the year (the Medicare recipient pays the remaining 20% coinsurance).

being "covered" under Social Security

Being "covered" means that the individual is participating in the program through regular tax contributions.

what does Medicare Part B cover?

Doctors office physicians office PART B = BMW = DOCTORS DRIVE BMW

being "eligible"

Generally, being "eligible" for benefits is based on the individual's "insured status"

Part C-Medicare Advantage Plans

HMO/PPO provided coverage. Can only get Part C if the beneficiary has both Part A & Part B. If the beneficiary buys Part C, then they don't need a Medi-Gap or supplemental policy. Subscribers may have to pay an additional premium for the coverage

Physician services in the hospital, doctor's office, or clinic are covered under:

Medicare Part B; additional premium due.

Claims and Appeals

Medicare claims are submitted by Medicare contracted participating providers and suppliers to the Centers for Medicare and Medicaid Services (CMS).

After receiving care by a doctor, how is the insured notified of Medicare's decision to cover the claim?

Notice from the Social Security Administration.

Part A — Hospital Insurance

Part A of Medicare pays for inpatient hospital care and certain follow-up care. It is mandatory that all workers covered by Social Security finance its operation through a portion of their FICA payroll tax. PAID FOR BY BOTH TAX FUNDS AND DEDUCTIBLE AMOUNTS Inpatient or outpatient physicians and surgeons' services. IS NOT COVERED!!!!!!!!!

, SOCIAL SECURITY, currently provides four main categories of benefits:

Retirement benefits for workers and their dependents. Survivors benefits for the family of a deceased worker. Disability Income for a covered worker and dependents. Medicare health insurance benefits for the aged.

Eight months ago, a man slipped and fell down a flight of stairs at home. As a result, he has a paralysis for which he is not expected to recover. This 40-year old person may be able to collect disability income benefits from which of the following?

Social Security.

What individual collecting Social Security benefits would be affected by a black out period?

THE INSUREDS SPOUSE

Cal-COBRA

THINK CONTINUATION applies to group with 2-19 employees after their benefits on COBRA end after 18 months, an additional 18 months of health insurance under Cal-COBRA can be purchased. can continue on CAL COBRA FOR UP TO 3 YEARS (36 months)

Part D — Medicare Drug Plans

The Part D program is administered by private insurers that are reimbursed by the Centers for Medicare and Medicaid Services (CMS).

VERY RESTRICTIVE DEFINITION OF DISABILITY

The individual must be disabled as the result of a medically defined physical or mental impairment resulting in the inability to perform "any substantial gainful activity." The disability must be expected to last (or has lasted) at least 12 months or is expected to end in death. IF THEY QUALIFY, THERE IS A 5 MONTH WAITING PERIOD

Blackout Period

The period of time between the youngest child turning 16 and the widow(er) reaching retirement age during which no Social Security Survivor Benefits are paid to the surviving spouse.

BLACKOUT PERIOD

The period of time following the youngest child's 18th birthday (or up to age 19 if still in school) until the surviving parent is eligible for benefits (age 60) During this time there are no Social Security benefits payable to the surviving parent.

medicare

This is a fee-for-service federal program that provides hospital coverage (Part A) and optional medical expense coverage (Part B) to citizens and legal residents (who have been in the United States for at least five years) age 65 and older, enrollment in Part A or Part C of Medicare satisfies the requirement for minimum essential coverage.

Currently Insured Status

To achieve CURRENTLY INSURED status the worker must have at least six credits earned during a 13-quarter period which ends with the calendar quarter in which the covered person died, became eligible for retirement benefits or became disabled. At least 6 quarters of coverage during 13 quarter period.

DISABILITY INSURED status

To reach this status, the individual must be fully insured and meet an additional requirement of recently earned credits, the amount of which varies depending on when the individual becomes disabled.

Medicare Assignment

an agreement between a provider and medicare to accept (participate) the fee schedule as payment in full for services (minus the appropriate deductible and co-insurance).

OBRA

an employer may terminate COBRA coverage because of coverage under another plan only if the other plan does not limit or exclude benefits for a qualified beneficiary's pre-existing condition. OBRA also states that COBRA coverage may be terminated because of both Medicare entitlement and enrollment, not just eligibility.

part c - Private Fee-For-Service Plans

can go to any Medicare-approved doctor or hospital that accepts the plan's payment. covers more services- gym mem, dental, vision, CALLED MEDICARE ADVANTAGE

Under social security, when does an individual receives retirement benefits?

depends upon THEIR DOB

FMLA

designed to help employees balance their work and family responsibilities by allowing them to take reasonable unpaid leave for certain family and medical reasons. employers with 50 or more employees must grant an eligible employee up to a total of 12 workweeks of unpaid leave 12 WORKWEEKS MUST BE PROVIDED IN A YEAR DUE TO PREGNANCY

being fully insured

entitles the worker and his or her family to retirement, premium-free Medicare Part A, and survivor's benefits. After an individual attains 40 credits/quarters (the equivalent of 10 years of work) the worker is considered fully insured even if there is no further employment.

TEFRA

has to have 20 or more employees its to prevent discrimination in group term plans it also amends the social security act and age discriminations TEFRA amends the Social Security Act to make Medicare secondary to group health plans for those employees eligible for Medicare

What does Medicare Part A cover?

hospitalization

DEFRA

imposes non-discrimination requirements on certain group plans, preventing more than 25% of total non-taxable benefits from being provided to highly compensated employees.

Medicare—Part D Prescription Drug Coverage

is a voluntary program for paying for your prescription drugs. If you earn more, you pay more.

Part B — Medical Insurance

is an optional coverage only for citizens and legal residents aged 65 or older, requiring a premium payment The federal government is required to make up the remaining 75% through general tax revenues. helps cover health care provider services and outpatient hospital care (e.g., diagnostic tests, durable medical equipment, and diabetic supplies) Part B provides benefits for diagnostic tests and x-rays performed on an out-patient basis.

Medi-Cal Share Cost plan

is the amount you agree to pay for health care before Medi-Cal starts to pay Partially state-funded benefits for low-income people whereby cost of care is shared between state & recipient, based on income. The share of cost is the amount of health care expenses owed to the provider of health care services that a recipient must accumulate each month before Medi-Cal begins to offer assistance.

COBRA

law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time. The law requires that employers with 20 or more employees provide for the continuation of the employer's group health benefits and options for former employees and their families After receiving notification of eligibility, employees have 60 days to elect a continuation of benefits or the option is forfeited. 18 months

social insurance

medical and social security - made for people who cannot afford other forms of health insurance and this comes from our tax revenues. the plans are administered by both federal and state government agencies and provide only a minimum floor of income.

ADA

prevents those employers from rejecting disabled job applicants on the basis that hiring them would result in higher group healthcare costs

MHPA

provided that certain group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical or surgical benefits

part c - Medicare Special Needs Plans

provides all Medicare Part A and Part B services to people requiring care for chronic illnesses or management of multiple diseases.

No Loss/No Gain Legislation

requiring that a replacement policy must provide continual coverage, or continue to pay ongoing claims under the policy it replaces without any exclusion of pre existing conditions. A 'transfer of benefits' statement is given to the customer to ensure benefits provided under the old policy will continue under the new policy.

PRIMARY INSURANCE AMOUNT (PIA

the amount of income the individual will receive after the average age the worker and average earnings under SS are taken into consideration

MEDI-CAL

the purpose of providing matching federal funds to states to support their medical public assistance plans for needy individuals of any age.