chapter 15 insurance for senior citizens & special needs individuals / Chapter 16 federal tax considerations for health insurance

the annual cost for long-term care service varies from one Geographic local to another, but they are High regardless of where one lives. Depending on the type of service required and rendered the annual cost can range from what?

$50,000 to $100,000 or more - easily enough to exhaust most people's assets

what does part (A)cover? how is it paid for?

(hospital insurance) covers institutional medical care, including inpatient hospital care, skilled nursing home care, post Hospital home health care, and hospice care. It is paid for by workers payroll taxes

what does Part (B) cover? who pays the premiums ?

(medical insurance ) covers Physician Services, outpatient hospital care, physical therapy, ambulance trips, medical equipment, and some preventive services. Part b supplement part A coverage. Everyone pays a premium for Part B coverage. The premium can increase for those with high incomes.

individually owned qualified long-term care policies get favorable tax treatments in what two ways?

1. benefits paid under the policies are not taxable within limits 2. premiums are deductible within limits to the extent title and burst medical expenses exceeded 10% of persons ATI 7.5% of AGI for persons who are at least 65 years old benefits paid under A LTC policy of to expenses actually and cured or daily limit $330 per day in 2015, whichever is greater Dasher. Tax. LTC premiums are eligible for medical expenses deduction, up to certain limit based on your age

eligibility for Medicaid assistance is fundamentally based on financial needs. most Medicaid funds are spent on the elderly oh, but no Marissa other groups received their share of Medicaid funding. Eligibility for Medicaid has determined by state requirements in what three areas? if assets exceed allowable limit, then the applicant must nearly do what?

1. disability or age 2. income limitations 3. asset limitations applicants must disclose all assets and sources of income. The formula used and the types of assets that are counted are complex and vary by state. applicant must nearly exhausted before becoming eligible. This is referred to as spending down. What's the assets and income or a low in enough according to State Standards, Medicaid will provide eligible people the nursing home benefits that Medicare specifically includes for example long-term care

HIPAA created two categories of long-term care insurance what are they? what is a tax qualified LTC policy? what is non-tax qualified policies? How does a policy become qualified? What are the qualifications?

1. tax-qualified policies - one that meets HIPAA requirements for benefits 2. non-tax qualified policies- does not meet the requirements. I tax qualified LTC policy has tax advantages not available to non-qualified policies if LTC policy meets the following requirements it would be considered a qualified LTC contract. Only qualified LTC contrast can be issued at partnership police • the only insurance benefits provided are for LTC services • the policy cannot reimburse any expenses reimbursable under Medicare • the policy must be guaranteed renewable • if it is a participating LTC policy, dividends can only be used to increase future benefits or reduce future premiums • it must meet other consumer protection requirements related to nonforfeitability

a Medicare beneficiary can receive how many continuous days of Hospital coverage.?

150 continuous days in hospital coverage, if necessary 90 days of one benefit period plus the one-time 60-day Reserve. However a co-payment requirement begins at day 61 and jump sharply with reserve days .

a person who has been a resident of State for ____ is eligible for coverage under South Carolina Health Insurance Pool if he she is uninsurable for medical reasons. The premiums for the schipper not heavily subsidized by the state, and that's very low-income individuals but seek Medicaid instead. Applicants currently in South Carolina Health Insurance Pool my opt out for an exChange plan instead in order to reduce cost. An administrator of the program overseas approval of all treatments and procedures covered by schip

30 days

Medicare Part A covers all ______ for up to ______ in any single benefit. After the part a deductible is paid. I benefit period ends ______ after released from the hospital . as long as a subsequent hospitalization period is separated by at least ______ from the previous hospitalization benefit period , a new ______ Will apply for the subsequent hospitalization. What's the hospital stay exceeds ______, the Medicare _____ of hospitalization coverage for a ______. Each of these days requires a daily co-payment multi twice the regular amount there is no limit to the number of ______ available to Medicare beneficiaries in addition to the ______Per hospitalization period , Medicare recipients have one time lifetime reserve of ________ of Hospital coverage. These are available by paying a co-payment _________ the reserve can only be used once in a person's lifetime. a Medicare beneficiary can draw upon the reserve _____ are depleted. Once the lifetime Reserve is used up, Medicare beneficiaries are responsible for all ______ that they are incur on any subsequent _______ benefit period

Eligible hospital costs / 60 days / 60 days / 60 days / 60 day benefit period / 60 days / beneficiary has 30 more days / total of 90 days/ 90 days / 90 day benefit period/ 60 additional days/ equal twice the regular amount/ once / one day at a time until 60 days / hospital costs/ 90 day

explain Part D eligibility

Medicare Part D prescription drug plan is available to anyone covered under the original Medicare Plan

what are the four parts of Medicare is divided into, what are they called?

a & b - call original Medicare which works in tandem to provide complete Medical Care coverage that is subject to deductibles and coinsurance. ( looks like a reimbursement insurance policy) c & d - more recent additions to the program, offer a managed care plan option(part c) and a prescription drug program (part d)

Medicare part A pays benefits, the insured was first pay what? after it is paid, Medicare does what?

a deductible at the beginning of each benefit. The deductible increases each year. after it's paid Medicare price fully for the benefits for the first 60 days of hospitalization. Medicare also pays benefits for the remaining time in the benefit period. from the 61st day to the 90th day, but the Medicare beneficiary must pay a daily okay payment amount during that period . the co-payment for days 91 through 150, the lifetime preserved eye is double the normal payment

Medicare was expanded to include another option, part c, what does that offer?

a full range of Medicare Parts A and B services to participants through managed care plans, such as hmos, ppos, and private fee-for-service plans. it brings into the program managed care providers, such as hmos and ppos by enrolling in part C and the Medicare program oh, a person chooses to receive his or her health care from my medicare-approved HMO PPO

explain Indemnity versus reimbursement contract

a long-term care Indemnity contract pays the full Daily benefit even if the cost of the Care is less, in this respect it is more accurately constitutes a value contract similar to a disability income contract. These are rare today the more common reimbursement contract limits daily benefits to the actual expense and does not exceed the maximum daily benefit amount specified in the policy

what are the South Carolina LTC partnership policies?

a person can I buy an LTC policy in which the benefits paid by a private LTC ensure our not counted in the Medicaid spend down and also will not be seized at the insured's death and Medicaid recovery procedure. All agents wishing to sell LTC in the state must have a certificate of completion of an 8-hour course in this partnership policy, in addition to the current life and health license. In each subsequent CEO compliance period, the LTC certification must be renewed with a 4-Hour course as well

what is Adult Day Care?

a provide socialization, meals oh, and activities. Facilities can be seniors with some mobility issues and Mild levels of cognitive impairment. They also allow home caregivers to continue working as the adult is well cared for during the day. Transport to the center may also be included

the cost of long-term care expected to rise greatly in the year ahead. For that reason, inflation protection is important. explain inflation protection

agents are required to advise perspective buyers that and inflation protection option is available at the additional Premium cost. Federal law makes inflation protection automatic on most partnership LTC policies. The increases may be 5% simple or compound, and benefit increases begin at the end of the first policy year. The proposed insured typically must reject inflation protection and writing

what does part C cover?

also called Medicare Advantage, is a managed care plan alternative to original Medicare. Provided through commercial insurance companies, this all-encompassing plan combines the coverage of part A and B in managed-care format with a restricted provider Network

well Federal Regulations mandate minimum eligibility standards for Medicaid benefits, States nonetheless have quite a bit of freedom and several program areas. Give an example for this

an example, they are allowed, within limits, to make their own rules about what is and is not covered by Medicaid

what can't an insurer do to an eligible person? what can't they exclude a pre-existing condition from?

an insurer cannot deny or condition insurance of a Medicare supplement policy to an eligible persons. It also cannot discriminate and setting it the premium for the policy on the basis of the person's health status, claim experience, receipt of health care, or medical condition, and cannot exclude a pre-existing condition from coverage during the open enrollment period , the six-month period following enrollment in Part B

how do you define pre-existing conditions? how many months can an insurer exclude benefits, and how?

and they cannot be defined more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a medical doctor within six months before the effective date of coverage. for the first 6 months the insurer can exclude benefits of coverage on the basis of a pre-existing condition for which the insurer receives treatment or was diagnosed during the six months before the effective date of coverage

what is a buyer's guide? when did they have to deliver the guide?

anyone eligible for Medicare who buys an accident and health insurance policy in South Carolina must receive a copy of the guide to health insurance for people with Medicare. Insurers are required to deliver this guide whether or not the person buys a Medicare supplement policy and must deliver it at the time of the application. Direct response in pictures are to deliver the guide to the applicant upon request but no later then when the policy is delivered

explain the eligibility for part C

anyone who is eligible for the original Medicare part A and babe plan qualifies for Medicare Advantage plan. They must reside in the play service area they select when enrolling in part C

when an employee reaches age 65 it is the employees option as to whether to sign up for Medicare drop the group coverage, defer Medicare or be covered by both plans. Employers are prohibited to give employees what?

are prohibited to give employees incentives to drop the company plan or coercing them groups of 20 or more, the group plan will be Primary in groups of less than 20 , Medicare will be primary

a return of Premium option Returns what?

are returns a part of the premium paid for LTC coverage to the insurance a state or to a named beneficiary when the insured dies. The amount of Premium returned is based on whether the insured use the policies benefits and if so, to what extent

how does a person 65 and over get free Medicare part a? can a person under 65 get free Medicare Part A coverage?

as long as a person or their spouse is fully insured., pray covered is also free for under age 65 who have qualify for Social Security disability benefits for a minimum of two years, have been diagnosed with permanent kidney failure known as in stage renal disease or have been diagnosed with ALS

explain taxation of group health insurance benefits

benefits paid through a group medical expense insurance policy or not taxable to the insured. Likewise, the insured is not taxed for health care services rendered through a group managed care plan. Insureds are also not taxed on benefits received under an ad&d policy.

individual LTC care policies are generally available to applicants between what ages? explain

between the ages of 40 and 85. Because most LTC insurance is sold to individuals, assessing the risk profile of any single candidate is an important part of the issuing and LTC policy. Llcc policies must be issued as guaranteed-renewable. The insurer is required to continue anyone applicants coverage for as long as he or she pays premium

Medicare supplement policies must provide for renewal or continuation, and state whether the insurer has the right to do what?

change premiums are automatically increase the premium based on the policy holders age. No later than 30 days for the annual effective date of any Medicare benefit changes, and it sure is required to notify policyholder of any changes it has made to its Medicare supplement policies

what is custodial care?

custodial care is provided to help a person need daily non-medical living requirements, like bathing, dressing, or eating. Well custodial care must be directed and monitored by licensed physician, it does not need to be administered by skilled professionals and is frequently provided by nurses aides or family members custodial care can be provided in nursing homes, assisted living facilities, Adult Day Care Center, respite centers or a person's home

Does Medicare provide long-term care coverage?

despite of common misperception it does provide very limited long-term care coverage, Medicare only cover the first 100 days of care in a skilled nursing facility and requires that a person first be hospitalized. And Medicare supplement policy cover the daily co-payments for nursing home expenses, but not Beyond medicare's 100-day benefit period. Medicaid, the provider of Last Choice does cover extended nursing home costs. However, to qualify for these benefits a person must spend down personal assets to near poverty levels

what is a Disability buy-sell Policy? are the premiums tax deductible?

disability buy-sell insurance policy provides funds to buy out the business interest of a business owner or partner who becomes disabled. It is thought on the lives of the business owners or Partners. It pays a lump sum benefit if an insured owner or partner becomes totally disabled. the business, in turn, uses the proceeds to buy out the disabled owner's interest. Disability buy-sell insurance is considered a discretionary expense and premiums are not tax-deductible. On the other hand, policy benefits or receive

what's an insured has met the benefit trigger, LTC benefit payments begin after satisfying policies what? as with disability income elimination periods, the deductible is not what? what do most insurers offer?

elimination period (waiting period) is that a dollar amount but rather a statement of how long the insured must use his own resources before benefits begin. Worcestershire sauce for the choice of 30, 60, or 90 days. The vast majority policies are issued with a 90-day elimination periods. A policy with a longer elimination period Generally cost less than one with a short elimination period.

also called the guaranteed purchase option, the guarantee of insurability option does what?

enables the policy owner to increase a daily benefit with no additional underwriting. The option to increase benefits become available every two or three years, depending on the contract, if any option is exercised, the premium increases based on the insurance age at the time of the increase

explain the initial enrollment period , what happens if they don't enroll early?

enrollment in Medicare is permitted up to three months before or up to three months after the month in Rowley first becomes eligible for Medicare, which for those who are not disabled his age 65. In other words, the initial enrollment. Equals a seven month. Including the month in which the recipient turn 65. Early enrollment is encouraged, in fact, those who wait for the last four months of their IEP to enroll will have a delayed start date of coverage of up to three months beyond their eligibility date

Medicare supplement policies provide a free look period for at least how many days?

for at least 30 days, during which the insurer can we turn the policy for any reason for a full refund of the premium paid

for caring a Skilled Nursing Facility to be considered necessary and thereby covered by Medicare, it must meet certain criteria, what are those criteria is?

for one, the care must be preceded by a hospital stay of at least three days for the same or related condition and admission to the Skilled Nursing Facility must be within 30 days of the time of the patient leaves the hospital. Second, the stay in the Skilled Nursing Facility must be at least 3 days long. Further, the beneficiary must have an approved plan of skilled care and be showing signs of continued Improvement

Medicaid has an important role to play in protecting children and other young people, and has been expanded under the Affordable Care Act to cover more people from what ages? explain how Medicare affects families and children with incomes at less than federal poverty threshold explain how Medicare affects blind or disabled or age 65 and older

from 19 to 64 in states that have chosen to expand coverage it is equally important to protect many elderly Medicare recipients. Children and Families whose income is less than a federal poverty threshold are generally eligible for Medicaid coverage under the children's health insurance program. those who are blind or disabled her age 65 or older are eligible for Medicaid if they meet income and financial resource requirements, Medicaid is an especially important service for elderly people, even those with modest Financial Resources, because the financial burden of long-term nursing home care and the high cost of catastrophic illness care can force many seniors to exhaust their Medicare benefits & overwhelm and personal savings

what does part C embrace? how do you enroll in part C?

full range of benefits offered by Parts A and B, and it may offer additional services such as prescription medications, physical exams, hearing and vision. To enroll in part C you must already be a road and covered by part A and Part B

an insurer cannot deny or condition issuance of a Medicare supplement policy or discriminate and its pricing on the faces of applicants health status and what other things?

health status, claims experience, Healthcare, or medical conditions when the application Esme before or during the six-month period beginning on the first day of the first month and wished applicant is at least 65 years old and is enrolled under Medicare Part B. Every Medicare supplement policy that an insurer cells must be made available to qualified applicants regardless of their age.

early LTC policies typically require the insurer to be what?

hospitalize you for a policies benefits are payable much as Medicare does today. Today's LTC policies cannot use prior hospitalization as a benefit trigger. In other words an insured cannot be required to have been hospitalized in order for a LTC policy to pay benefits. All that is required is a report from a person's family physician a testing to report the six basic activities as a trigger for the benefits.

explain under the obra how it affects kidney failure

if an employee develops ESRD or chronic kidney failure during employment, the employers plan must provide primary coverage for the first 30 months the employee is on Medicare. After that point Medicare becomes primary

what year did Medicare programs expand to include part D?

in 2006

insurers are required to provide an outline of coverage about the Medicare supplement policies at the time a person applies for coverage. what does the outline include ? can a Medicare supplement offer benefits that duplicate the benefit Medicare provides?

includes information about the premium, discloses important information about the policy and the coverage, and shows charts that display the features of each benefit plan ensure offers. The applicant must sign a receipt for the outline of coverage. A Medicare supplement cannot offer benefits that duplicate the benefit Medicare provides

what is renewability

individual LTC insurance policies issued in South Carolina must be guaranteed renewable. This means that the insured can continue the insurance by paying premiums on time. The insurer cannot change any provisions while the policy is in force, and cannot refuse to renew the policy. However, it can change the premium rate for a class of insured

explain special enrollment period . is there a penalty for late enrollment?

individuals who are working and covered under their employer medical plan May defer coverage a Medicare Part B until they actually retire. For these individuals a special enrollment period allows them to sign up for Part B after they're IEP without penalty. The SCP is available anytime during the eighth month. That begins the month after the employment of the group health plan coverage ends, whichever happens first. A late enrollment penalty is typically not required for beneficiaries to enroll during an SEP

explain replacement in Medicare, what happens if a Medicare supplement policy replaces another Medicare supplement policy.? What if the policy has been in effect for at least 6 months?

insurance and agents are required to determine from an applicant whether he or she has a Medicare supplement policy, Medicare Advantage, Medicaid coverage, or another health insurance policy in force they are also supposed to determine whether a Medicare supplement policy is intended to replace an existing health insurance policy. if a Medicare supplement policy replaces another Medicare supplement policy the replacing insurer let's wait any pre-existing condition periods , waiting periods, elimination periods , & probationary periods and replacement policy to the extent these periods were satisfied under the original policy. If a Medicare supplement policy replaces another Medicare supplement policy that has been fetched for at least 6 months the replacing insurer cannot impose any new periods for pre-existing conditions, waiting periods, elimination periods & probationary periods

explain inflation protection, what if he chooses not to purchase inflation protection?

insurers are required to offer individual can you buy an LTC insurance policy the option to buy inflation protection so that benefit levels will increase to keep Pace with inflation. The insured typically has a choice of opting for simple or compound inflation protection. If he chooses not to purchase and place your protection, a statement indicates such must be signed at the application

what is Medicare?

is 4 people age 65 and older and for certain disabled individuals. Medicare is a broad breaching Social Security program that provides medical expense coverage for those whose qualify. Like Social Security, Medicare is a pay-as-you-go system funded primarily by payroll.

what is eligibility for Medicare Part B

is voluntary and available to anyone who qualifies for Medicare part A. Online part A, Part B requires that the insured pay an income - adjusted monthly premium

what is long-term care? is the need for this type of carry spected to grow? What type of assistance does it provide?

it is a broad term that includes many different types of care to suit a variety types of care in places where the carrots delivered. as the u.s. population ages a life expectancy increased, the need for this type of care is expected to grow exponentially long-term care is not the acute care needed after a heart attack. It is assistance in accomplishing activities of daily life, such as going to the toilet, or moving from room to room for a person with impaired mobility. And impaired person living at home we need help and everyday activities, which is what long-term care insurance provides.

explain accelerated benefit Rider? The LTC endorsement is considered what?

it is considered a living benefit, because it provides financial support for the cost of Medical Care, nursing home care, and assisted living care while the insured is a lot. And it should have bought an LTC Rider becomes eligible for its benefit when he or she is diagnosed as chronically ill. This diagnosis can be the result of either a medical or cognitive mental health condition. The insured can then use some of the death benefit top cover long-term care costs and the beneficiary receive the unused benefits at the insured's death. If qualify for a medical reason, than the insured generally must be certified as unable to perform at least two activities of daily living or have a diagnosis of cognitive impairment

how do you get Medicare Part D?

it is optional for anyone who is covered under part A or B if there is also Medicare Part C plans which have drug coverage

what is a more affordable alternative to Medicare supplement insurance?

it is the Medicare select plan. Whereas Medigap policy is a traditional Indemnity policy, a Medicare select plan is a Managed Care alternative. In fact, this is exactly what a Medicare select plan is, a managed care plan that requires seniors to receive their carries clusive Lee from provider Network established by the Medicare select plan. Does a Medicare select policy is in Medicare supplement policy that contains restricted network access and would then generally be less expensive than an equivalent Medicare supplement

explain private fee-for-service plans

it operates as Medicare approved private insurance plans with a PFFS plan, Medicare pays the private plan for traditional Medicare cover services, in the PFFS plan determines which additional Services it will cover what share of expenses the Medicare beneficiary will pay towards those Services. It is in addition to the standard Medicare Advantage plan and one of the two related forms

what does Medicaid provide? who funds it? who funds it?

it provides HealthCare coverage and health-related services to people with low income and other needy individuals. It is jointly funded by the federal and state government, but it is administrated by the States. Federal government pays for a specified percentage of program expenditures which varies by state based on criteria such as per capita income

explain business overhead expense insurance

it provides funds necessary to continue business operations if the insured owner or partner becomes disabled. It covers most of the overhead expenses required to keep the business open during the insurance disability. Premiums are deductible as an ordinary business expense, and benefits are received by the business as taxable

what is a key person disability income policy?

key employee disability income insurance is designed to provide businesses with the funds needed to make up for lost revenues due to a key employee disability. Since the policy benefits are paid to the business, premiums are not tax-deductible however benefits are also income tax free

self-employed people can deduct the cost of their personal health insurance for themselves and their families - ________ - as an above-the-line expense this means they do not have to itemize to take the _____. premiums for long-term care insurance are also deductible up to a limit based on the _______. This limit is adjusted periodically

medical & dental / deduction / persons age

plan a represents the basic core or sometimes called the basic benefits. Each of the remaining plans contain the basic core benefits available under plant a plus additional benefits. the core benefits include what? specifically what are the core benefits?

most Medicare part A and B co-payment and coinsurance amounts, blood, and additional Hospital benefits not covered by original Medicare • part a hospital co-payments for days 61-90 • part a hospital KY payments for Lifetime Reserve days 91 -150 • an extra 365 days of inpatient hospital care after depletion of the original Medicare Hospital benefits • Part B coinsurance after meeting the annual deductible • Parts A and B blood coverage - the first three pints you must pay for • 4/8 hospice - $5 copay for drugs for pain relief and 5% coinsurance for inpatient respite care

group health insurance is considered a reasonable and _________. As such, the employer can deduct the premiums it pays for a group health insurance plan. Employees are ______ on employer-paid premiums because health insurance benefits are not _______. Like individual medical insurance policy premiums, employee premiums contributions may be included with other non-reimbursed medical expenses and deducted to the extent the some of those expenses exceed _____ of his or her AGI

ordinary business expense/ not taxed / considered wages/ 10%

for many years Medicare part A and B constituted the entire Medicare program today they are called what?

original Medicare

in addition to covering Hospital Services, Medicare part A covers medically necessary skilled nursing care. Medicare part A pays how much for care in a skilled nursing facility for how many days? is there a co-payment and if so how much is it?

pays the full cost for care in a skilled nursing facility for the first 20 days of such care. Skilled nursing care continues to be covered beyond the first 20 days. However, the patient must pay co-payment amount of $161 per day. No Medicare benefits are available for Skilled Nursing Facility care that extends Beyond a hundred days

explain taxation of disability income insurance for both individual & group , what is taxable?

premium set individuals pay for disability income policies they are not tax-deductible. And return the benefits the policy pays are received entirely tax-free. In group insurance plans, where the employer pays the premiums, the business can deduct premiums and the premium payments are not considered taxable income to the employee. However, any benefits pay to the employee under his such policy are taxable income to him or her

what does Part D cover?

provided through Medicare approved commercial shirts it adds prescription drug coverage to Medicare Parts A and B

explain General enrollment period

qualified individuals who did not sign up for part A or Part B during IEP but they are first eligible must then wait until the next general enrollment. Between January 1st and March 31st each year. Coverage will begin July 1st. It may be necessary to pay higher premiums for light enrollment unless covered by another group plan

explain annual election period

qualified individuals who wish to change Medicare Advantage plans, switch from traditional Medicare plan to a Medicare Advantage plan, or change Part D prescription drug plans may do so during an annual election perod , sometimes called the open enrollment period The AEP runs from October 15th through December 7th, new coverage becomes effective the following January 1st

what does Medicare assignment refer to? what is participating providers? what can non participating providers elect?

refers to the agreement between a healthcare provider and Medicare. participating Medicare providers agrees to always accept assignments which means they've agreed to charge no more than medicare-approved amounts for specific treatments and services. The amount of Medicare approved for these treatments and services would be considered payment in full. they can elect to accept assignment on a case-by-case basis. Medicare-eligible individuals who are treated by participating providers Payless for covered services and treatments

Riders and endorsements added to an individual LTC insurance policy after it is issued or at ______ that reduce or eliminate benefit or coverage must have the insurance sign acceptance before they can become effective. riders or endorsements added to an individual LTC insurance policy that _______ with a corresponding increase in premium must also have the insurance acceptance, unless they're _______. If an LTC insurance policy limits benefits for __________, the _______ must be made clear in the policy. Any other limitations are conditions must also be made clear

reinstatement or renewal / increase benefits or coverage / required by law / pre-existing conditions / limitations

Medicare part A covers all the costs of a hospital stay including what? what is not covered?

semi-private rooms, meals, General Nursing, and drugs as a part of your inpatient treatment, and other Hospital services and supplies, it includes the care you get in an acute care hospitals, critical access hospitals, inpatient Rehabilitation Facilities, long-term care hospitals, and patient care is part of a qualifying clinical research study, and mental health care. what is not covered are private duty nursing, private rooms unless medically necessary, television and phone in your room if there's a separate charge for these items, and personal care items, like razors or slipper socks

Insurance cannot exclude clients based on pre-existing conditions for more than how many months after a policy effective date? the craziest in condition cannot be Defined how?

six months after a policies effective date. aprisa stin condition cannot be defined more restrictive Lee then a condition for which medical advice was given a treatment recommended by or received from a doctor within six months before the effective date of coverage.

long-term care insurance contracts are available in two forms, what are those forms?

so-called indemnity contracts or a reimbursement contract

contributions by individuals, within the IRS limits are _______ as an above-the-line deduction and not just as in itemized deduction. This plan can be used by people feeling a short form. Contributions to employee HSA accounts by employers ______ for the employer, and income tax free benefits to the employee as long as use for eligible expenses

tax deductible / tax deductible

who are the prices for most Medicare approved medical service set by? how are Medicare benefits paid?

the CMS. Healthcare Providers Bill Medicare directly for services surrendered to Medicare patients, so there are no claim forms. intern Medicare benefits are paid directly to the health care provider. And this way the Medicare system function much like a preferred provider organization PPO managed care service with a few important differences

what does Part D require? what are the minimum standards for Part D? explain the different drug cost at coverages, when can a Medicare beneficiary change their coverage?

the price of a monthly premium that vary from plan to plan. I'll plans must at least meet the minimum standards. at level 1 coverage, the insured pays 25% of the drug cost after deductible up to a certain amount of total cost plans that hit the coverage Gap or donut hole that requires a plan beneficiary to pay all drug costs out-of-pocket. Start enlisted name brands are discounted 50% and the donut hole. After reaching the plans up out-of-pocket limit during the coverage Gap, drug coverage resumes for the balance of the calendar year, the beneficiaries required to pay 5% coinsurance amount for the prescription drugs. Medicare beneficiaries man role, or change, their Plan D coverage during the annual enrollment period which runs from October 15th through December 7th. New coverage becomes effective the following January 1st

there are 10 standardized Medicare supplement plans play but a through n. These plans have been sterilized because the NAIC wrote the guidelines which were adopted under the 1990 OBRA law. consumers can dust compare plans based on what? At all companies selling Medicare supplement policies must sell what? And to make it easier for the consumers to understand the options on Medicare supplement policies must conform to what? are Medicare supplement policies guaranteed-renewable? How do they adjust their benefits?

the service cannot compare plans based on price and Service as benefits are standardized. Each plant offers a slightly different set of benefits. all company selling Medicare supplement policies must sell plan a and either plant sea or plant us. They may sell any or all of the other plans as well. To make it easier for consumers to understand there are options, all Medicare supplement policies must conform to Federal standards for the 10 standardized the forms. For example and insured that sells plan a must sell a product that exactly and conforms to plan A - nothing more, nothing less. Furthermore, insurer must include the plan code A,B,C Etc and the product name. As Medicare adjust It's deductible and co-payments, Medicare supplement policies must align their benefits to match the adjustments Medicare supplement policies must be guaranteed renewable

long-term care insurance can be issued in three ways what are they?

they are mainly issued on an individual or group contract basis. Group plans are available both to employer groups and associations such as alumna groups. But in recent years a third way to issue long-term care insurance has evolved as an endorsement Rider to a life insurance policy

what is the purpose of Medicare supplement plans? who are they under written and sold by? well they cover plan C plans? is anyone in Medicare entitled to purchase a Medicare supplement? What are the criterias to purchase Medicare supplement? What if they meet this criteria?

they are on the written and sold by commercial insurance companies not the government , Medicare supplement policies are designed solely to supplement original Medicare. Notice that the Medigap policies are not intended to supplement Medicare Advantage plan C plans, because those plans are already cover many of the gaps that a Medigap policy is intended to cover. Some Medigap plans offer benefits that Medicare doesn't, such as emergency medical care in a foreign country federal law ensures that people who qualify for Medicare are entitled to purchase a Medicare supplement policy regardless of their health condition, as long as they are 65 and older and apply for Medicare supplement policy within six months of enrolling in Medicare Part B. If they meet this criteria, then they qualify for the policy of their choice within their state. The insurance company cannot deny air condition this issue of the policy because of one's medical history, health status or charge you more for the coverage during 6 months

a producer's commission for the sale of a Medicare supplement policy in the first year following its effective date cannot exceed what percentage of commission paid for what? commission for subsequent renewals must be what? It must be paid for at least how many renewal years?

they cannot exceed 200% of the commission paid for selling or servicing the prophecy in a second year. commission for subsequent renewals must be the same as that for the second year must be paid for at least 5 renewal years. If it is a replacement, first-year commissions cannot be paid unless the benefits in the replacing policy are clearly and substantially greater then the policy being replaced

the original Medicare program, consisting of her Aid and Bee Remains the primary way in which Medicare approved services are covered. However, part A and B have a number of gaps in their stubbard. Leaving the responsibility for covering the cost of those gaps to Medicare recipients. what do the gaps include? to fill these gaps an original Medicare coverage the answers industry created what?

they include the part a deductible and daily co-payments for hospitalization and nursing home care. They also include the part B deductible and it's required 20% coinsurance for a co-payments. they created Medicare supplement policies also known as Medigap policies

are Medicare supplement policies renewable?

they must be guaranteed renewable yes

in Medicare Part B, the recipients paid their portion of what they owe for what? does the provider get reimbursed? what is an excess charge?

they pay their portion that they owe for the deductible and coinsurance directly to the provider. The provider bills Medicare for its portion of the charges, Medicare reimburses the provider directly. If Medicare denies payment for any treatment or Services the recipient receives come here she can appeal the decision directly to Medicare. there is no maximum on the 20% coinsurance the beneficiary must pay during the year, so someone with a $400,000 surgical procedure would still have to pay 20% or $80,000. if the physician or medical supplier does not accept assignment, they are allowed to charge up to 15% above the medicare-approved amount. This is called the excess charge and the Medicare beneficiaries required to cover all of it

but they tax qualified LTC plan, premium payments are considered what?

they're considered a qualifying medical expense for federal income taxes. Subject to limit, they may be included with other out-of-pocket medical expenses and qualifying for the medical expense deduction

what is skilled nursing care?

this is a continuous, 24-hour delivered by licensed medical professionals, under the direct supervision of a doctor or physician. Skilled nursing care is usually delivered in a Skilled Nursing Facility

what is intermediate care?

this is ongoing care necessary to address a person's condition but not needed 24 hours a day. Intermediate Care is delivered by registered nurses, licensed practical nurses, and nurses aides, who are being supervised by dr. Typically provided to patients who are recovering from acute medical conditions, Intermediate Care is usually delivered in a nursing home or rehab facility, but depending on the individual case it can also be provided at one's home, and assisted living facility, or a community-based center

explain Medicare enrollment, a person who wants to enroll in Medicare at age 65 but chooses to defer Social Security retirement should still consider what?

those who apply for Social Security retirement benefits at age 65 may become enrolled in Medicare Parts A and B. Part B coverage requires a premium to maintain, and new enrollees who do not want Part B coverage must contact the CMS to opt out. At the time they become eligible for original Medicare, enrollees May instead opt out for part C (Medicare Advantage) coverage a person who wants to enroll in Medicare at age 65 but chooses to defer Social Security retirement should still consider enrolling in part A as the worker has paid for it and it may become secondary covers to his existing Group Insurance

under the 1990 obra law, what was the special provision for employees in large group plans?

those with a hundred plus employees, these plans must provide primary coverage for disabled employees under 65 they were conquered by the group and Medicare

when recommending the purchase over placement of a Medicare supplement policy, an agent must attempt to determine whether the policy is what? A cell of a Medicare supplement policy that results in the insured having more than one Medicare supplement policy is what?

to determine whether the policy is appropriate for individual, and any sell a Medicare supplement policy that results in the insured having more than one Medicare supplement policy is prohibited

unlike parte, which is available without a premium to those who qualify, Part B required file Medicare beneficiaries to pay what? after the deductible is paid how much does Medicare pay? what is Medicare approved Healthcare charges based on?

to pay a monthly premium based on the insurance annual income. to start the insured must pay an annual deductible. After paying the deductible, Part B pays 80% of Medicare approved Healthcare charges. Medicare approved Healthcare charges are based on usual and customary charges that Prevail in the community in which care is delivered

Medicare Part C HMO and PPO care providers enter into an agreement with Medicare, to provide what?

to provide approved services to Medicare beneficiaries for set monthly payment provides to the insurance plans for Medicare. for this reason there are several no premium for low premium plans if I have a blast to pull them out allocated to the provider.

what is respite care?

under Medicare it is a short break to shop or just get out of the home where someone is caring for a loved one. Medicare provides very limited amounts of these break occasions but only if a person is caring for someone in a hospice situation. And individual LTC policy, however, May provide for 24-Hour aids to watch over the insured or the insured a temporary stay in a nursing home for 10 days or two weeks a year. This valued benefit allowed to caregivers some time to get out from under the burden of care

explain taxation of group disability benefits

what's your disability income policies, the tax treatment of benefits is slightly different. With group d i whatever percentage of the premium the employer pays as a percentage of the plan benefit upon which the employee is tax. This is true both with short term disability and long-term disability benefits

explain replacement in LTC insurance policies what show application forms from LTC insurance policy state? If the sale involves replacment the insurer or producers required to provide what?

when soliciting or selling LTC insurance policies, insurance and producers are required to follow the usual rules concerning replacement. Application forms for LTC insurance policies must seek information from the applicant to indicate whether he or she has another LTC insurance policy in force or whether analysis the insurance policy is intended to replace another help or LTC insurance policy already in Force. If the sale involves replacement, the insurer or producer is required to provide the applicant with a notice to applicant regarding replacement of accident and health insurance. This notice must be given when the producer takes the application. The insurer or producer is also required to give the applicant a complete, written comparison of the benefits offered by the new policy in the policy that will be replaced

is there coverage for an active worker over age 65? will it effect there SS benefits?

yes persons over age 65 who continue to work and are covered under an employee great plan can also be covered under Medicare. For Medicare coverage does not affect the amount of their future Social Security benefits. When they file a claim, their employer group plan generally is primary payor and Medicare is the secondary payor.

applicants for individual LTC insurance policies are entitled to an outline of coverage when they apply for coverage. a signature from the applicant will verify receipt of this document. The outline must include what information about the policy?

• a description of the benefits and coverage • a statement of the exclusions, reductions, and limitations • a statement of the renewal provision as well as a notice that the insurer has a right to change the premium • a description of the right to return the policy within 30 days (free look) • a description of the relationship of cost of care and benefits

the term self-employed person includes what three things

• a sole proprietor • a partner • an S Corporation owner who owns more than 2% of the outstanding shares

the following acts are considered to be unfair, deceptive, or unreasonably confusing acts when used to solicit or sell individual accident and health insurance the persons who are or may be eligible for Medicare

• any act that may induce a person to purchase coverage she may not really be able to afford, or which would duplicate any existing policies • encouraging and applicant to omit relevant underwriting information from an application • any act that may induce a person to sign a blank or incomplete application • when first Contracting a person, failing to disclose the fact that the person making the contact is an insurance producer • representing that a producer is authorized by or affiliated with a specific, social, or other non-government organization, unless that is true • using false or misleading statements concerning how long it Insurance product may or may not be available • selling a policy that the commissioner has not approved for sale • selling a Medicare supplement policy to any person who is not eligible for Medicare, to a person without asking if a person has a current Medicare eligibility card, or to a person who has a current Medicare eligibility card • falsifying a document that the producers required to complete • failing to submit to the insurer within seven business days to premium collected from an applicant • failing to deliver to the applicant within 7 business days a policy that the insurer has issued • taking an application without determining whether the proposed insurance will duplicate any insurance already in force • asking questions in a way that would get an answer that is not factual

the following persons are not eligible for coverage under a state's Insurance Pool

• anyone already covered under health insurance that is comparable to the covers the pool offers • anyone who is eligible for health care benefits from State Medicaid or Medicare and who is at least 65 years old • anyone who terminated covered in the pool less than 12 months before applying for coverage again, unless the termination was due to an eligibility • anyone who has received $1,000,000 in benefits from the pool • inmates of public institutions in persons eligible for public programs • anyone who is not South Carolina resident best chip provides major medical hospitalization coverage only after 6 months pre-existing condition exclusion period

premium free part A is available to the following individuals

• are age 65 and older and have earns 40 quarters of coverage under Social Security • are age 65 and their spouse is at least 62 and it's fully insured under Social Security • have been receiving Social Security disability checks for at least 2 years at any age • have end-stage renal disease which is kidney disease requiring a transplant or dialysis • have Amy atrophic lateral sclerosis ALS, or Lou Gehrig's disease note that the eligibility age for Medicare main 65 even though Social Security full retirement age age of one May receive full Social Security retirement benefits is now 66 as gradually increasing to age 67.

first LTC policies have benefit limits, defined in terms of what? what are the common benefit periods range from? And what are the benefit amounts normally specified at ?

• benefit amount, the dollar amount that will be paid for qualifying care, typically expressed as a daily amount • benefit period, the length of time for which benefits will be paid common benefit periods range from two to five years, though some policies may offer lifetime benefits. Many ensures are offering benefit periods up to 10 years, but few lifetime benefit policies are still written. benefit amounts are normally specified as a flat daily amounts, such as $50, $100, or $200 a day

the marketing Medicare supplement plans in South Carolina what must the insurer do?

• develop marketing procedures to ensure that any comparison of its policies by producers is fair and accurate • develop marketing procedures to prevent the sale or issuance of excess of insurance • displaying artist on the first page of every policy that says notice to buyer, this policy may not cover all of your medical expenses • reasonably try to determine whether a prospective applicant or in Raleigh for Medicare supplement insurance already has accident and sickness Insurance, the types and amount of that insurance • develop a means by which examiner's can audit the insurers marketing procedures

what federal standard set the minimum standards for Medicaid Eligibility, each state has flexibility and what services will be covered. For Medicare beneficiaries who are eligible for their State Medicaid Program, Medicaid services as the secondary insurer. Medicare is the primary insurer. the general types of covers that Medicaid May provide, depending on the state include what?

• doctor and surgeon fees • emergency care • hospital care • vaccinations • Dental Care • Podiatry • prescription drug costs • vision and hearing care • Mental Health Services • medical supplies and equipment • prosthesis • X-ray and lab services • hospice care • transportation to services • long-term care

long-term care insurance recognizes six basic activities of daily living what are they?

• eating • dressing • transferring (moving from a bed to a chair, for example ) • bathing • toileting • continence (the ability to control urinary and bowel functions)

part A covers hospice care for terminally ill Medicare beneficiaries who are what?

• eligible under benefits part a • have been certified by doctor as terminally ill with a life expectancy of six months or less • false statement choosing to waive all other Medicare coverage for care for hospice programs other than the one chosen • choose not to receive other services related to the treatment of the terminal condition

Medicare part A is Hospital coverage. Within certain limits what does it cover?

• inpatient Hospital costs • Skilled Nursing Facility costs • home health care cost • hospice cost for Medicare to cover these costs, the cost must be reasonable and medically necessary

part b Medicare program, available to those who are covered under part A, provides coverage for medical care beyond hospitalization. The maid services provided under Part B are doctor's Services no matter where we received in the United States what are the other covered services?

• inpatient and outpatient medical surgical services and supplies • physical and speech therapy • occupational therapy • outpatient diagnostic tests and x-rays • medical supplies • initial welcome to Medicare physical and subsequent annual Wellness

the second alternative for Medicare Advantage just a special needs plan, created through the Medicare modernization Act of 2003. it is available only to special needs individuals who fit one of the three categories, what are the three categories?

• institutionalized • dually eligible for both Medicare Medicaid • have severe or disabling a chronic medical conditions

Medicare Part B is not all inclusive. What are excluded from the part B coverage?

• most prescription drugs • routine Eye Care & Eyeglasses • hearing aids and hearing exams • dental care except due to an accident • Healthcare received outside the United States • Skilled Nursing Facility care • cosmetic surgery • personal Comfort items • charges above the medicare-approved amount • losses due to war

are a covered Hospice Services include what? do hostas benefits have a deductible, does Medicare pay a reasonable cost of providing hospice care? Is there a copay for drugs or pain relief? Is there any coinsurance?

• nursing care • medical social services • counseling • short-term inpatient care and respite care temporary relief given to those caring for family members at home • medical appliances and supplies • Services of a home health aide • Homemaker services • drugs • physical and occupational therapy the benefit. For hospice care consist of two 90-day periods and unlimited number of 60-day extensions of benefits the hospice benefit has no deductible. Medicare pays reasonable cost of providing Hospice Care. Respite care cannot exceed 5 consecutive days. There may be a $5 copay for drugs or pain relief and a 5% coinsurance amount for the inpatient respite care

Medicare part A also covers home health care. what do covered Services include? our prior hospitalization required for these services to be covered? Is there a maximum number of allowable Home Health Care visits? how much do they pay for Approved services and medical equipment?

• part-time or intermittent skilled care • home health aide services • durable medical equipment and supplies • certain other services nope prior hospitalization is required for these services to be covered, there is no maximum number of allowable Home Health Care physics. Medicare part A pays 100% of approved amount for services. It also pays 80% of the approved amount for durable medical equipment, such as wheelchairs

long-term care policies cannot exclude or limit benefits by type of illness particularly Alzheimer's disease, treatment, medical condition, more accident. However LTC policies issued in South Carolina can exclude the following from coverage

• pre existing conditions or diseases • mental or nervous disorders except those specifically that qualify for benefits such as Alzheimer's disease • alcoholism and drug addiction • illness, treatment or medical conditions arising from war or act of War, participation in a felony, Riot, or insurrection, service in the Armed Force or auxiliary, suicide, attempted suicide, or intentionally self-inflicted injuries • services for which Medicare pays benefits • services for which state or federal workers compensation pays benefits

South Carolina regulations affecting Medicare supplement policies are intended to do what things?

• standardized coverage offered by these policies • Health Department understand these policy so they can compare them • eliminate confusing or misleading provision and these policies • provide full disclosure and sales of accident and health insurance coverage two persons eligible for Medicare

in addition to the usual standards for accident and health insurance policies issued in South Carolina insurers that issue Medicare supplement policies must adhere to the following standards Medicare supplement policies cannot indemnify against losses resulting from sickness on a different basis then losses resulting from accident. A Medicare supplement policy cannot do what?

• terminate a spouse's coverage only because the insurance coverage has terminated, other than for failure to pay the premium • be cancelled or non-renewed by the insurer only on the basis of the insurance deteriorating health • the council or nonrenewable the insurer for any reason other than material misrepresentation or failure to pay the premium

an LTC policy provides benefits after the insured meets a benefit trigger as defined in the policy. Benefits can generally be triggered by what?

• the insured's inability to perform two or more activities of daily living (ADL'S) • the insurance loss of cognitive abilities such that it limits his or her ability to care for himself or herself without help or supervision (cognitive abilities include the ability to think, reason, perceive, or remember) • medical necessity

if a person meets any of the following they would be eligible for coverage under a state's Insurance Pool

• the person apply for health insurance from private insurers but was refused for health reasons • the person can buy health insurance only with a pre-existing condition exclusion period that is longer than 12 months • the person can buy health insurance comparable to pool coverage but at a rate that is more than 150% higher than the pool rate

in addition to the usual probation's in marketing life and health insurance policies, ensures and producer selling Medicare supplement policies cannot engage in what?

• twisting or high-pressure tactics • misleading advertising, example failing to disclose that the intent of the advertising is to sell insurance and that a producer insurance company will contact the prospect