CH 9
Types of Dental Insurance
Diagnostic and Preventative, Restorative, Oral Surgery, Endodontics, Periodontics, Prosthodontics, Orthodontics
Non-Schedule Plan Services
Diagnostic/Preventative; basic services; major services
Loss Ratio Standards
In order to control the costs of Medicare Supplement Policies, the government has regulated their profitability. In selling group policies, companies must pay out in benefits at least 75% of the money that they collect in premiums. In selling individual policies companies must pay out 65% of the money they collect in premiums
Enrollment
Medicare Part A is mandatory, automatic, and is provided free at age 65 for individuals that qualify. An eligible person can enroll in Part A of Medicare on the first day of the month in which they reach age 65. in the event that a person does not qualify for Medicare, it can be purchased for an additional cost on the first day of the moth in which they reach 65 with a 10% penalty. Part B of Medicare is optional or voluntary, because it contains an additional premium payment. If an individual elects Medicare Part B during the initial enrollment period, a premium is required which is directly deducted from the individual's Social Security benefit. The initial enrollment period begins 3 months prior to turning 65 includes the birth month and continues for three additional months after the 65th birth moth for a total of 7 months. If an individual becomes eligible for part B and declines it he/she must wait until the next general enrollment period which is from January 1st through March 31st. Under those circumstances coverage would not begin until July 1st.
Medicare Part C
Medicare advantage, used for people who have both Part A and B, a Medicare Advantage plan covers most of the same benefits as a Medigap Policy. These plans are provided through private sector insurance companies and they typically provide expanded benefits depending on the type of plan. Provides all Part A hospital and part B medical coverage.
Guaranteed Issue and Preexisting Conditions
No company can deny or condition the issuance of a Medigap policy based on age or other medical history or condition when the application for a Medicare supplement is made during the initial 6 month enrollment period. preexisting conditions cannot be excluded for more than 6 months form the date of issue
Required Provisions in Medicare Supplement Policies
Open Enrollment Period, Buyers Guide, Free Look, Guaranteed Issue and Preexisting Conditions, replacement, Compensation, Loss Ratio Standards, Medicare Select
Core Supplement Benefits
Pay for Medicare Part A Co-insurance for hospitalization from the 61st day through the 90th day in any Medicare benefit period; Pay for the Part A Medicare co-insurance amount for hospitalization for each Medicare lifetime inpatient reserve day used; Upon exhaustion of the Medicare Hospital inpatient coverage, it pays for the Medicare Part A eligible expenses for hospitalization, subject to a lifetime maximum benefit of an additional 365 days; Pay for the reasonable cost of the first 3 pints of blood, under medicare parts A and B; Pay for the coinsurance amount or the co-payment amount of Medicare eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B Deductible (80/20)
Who isn't covered by Social Security
Railroad workers are covered under a separate federal program (Railroad Retirement System), therefore they are not covered under the Social Security System. SOme government employees, and most federal employees hired prior to 1984
Medicare Part D - Prescription Drug Coverage Act of 2003
Requirements for coverage - provided through PDP that contracts with Medicare. To qualify a person must be enrolled in Part A or in Part B or Medicare Advantage. Monthly premium of $30 and a deductible of $310 with a maximum benefit of $2840. When the individual reaches the maximum benefit of $2840 coverage stops and the beneficiary is responsible for 100% of costs. However, when the gap reaches $4,550 catastrophic coverage will set in and 95% of prescription costs will be covered. The gap in coverage when no benefit was received is called the "Doughnut Hole." IF someone did not enroll during the initial enrollment period and decides to enroll later, they will pay a 1% penalty for each month of delayed enrollment
Endodontics
Treatment of the dental pulp within natural teeth, such as root canal
Free Look
all policies must contain a 30 day free look period, along with a Buyer's Guide an outline of coverage, to provide for full and fair disclosure in the sale of Medicare supplement policies
Compensation
an insurance may pay compensation to an agent for the sale of a Medicare supplement policy. The first year's commission may be no more than 200% of the renewal commission for servicing the policy in the second year, and the renewal commissions paid for years 3 through 6 must be as high as the second year's commission. Compensation on a replacement policy cannot be greater than the amount that would be received on the renewal of the policy
Buyers Guide
any accident and sickness policy issued must include a Buyer's Guide, Policy Summary, and Outline of Coverage. Buyer's Guide is provided at time of application, Outline of coverage is sent by the insurer at the time of delivery of the policy
Eligibility
anyone reaching age 65 and qualifying for social security benefits is automatically enrolled into the Medicare part A system and offered Medicare Part B regardless of financial need. People born prior to 1929 are eligible even if they do not achieve the 40 quarters of eligibility for social security. A spouse of an individual who qualified for Social Security benefits prior to death is also eligible to enroll at age 65.
Scheduled Plans
basic plans, pay benefits from a list of procedures up to the amount shown on the schedule. They are provided with first dollar coverage without deductibles or coinsurance
Non-scheduled Plans
benefits are paid on a reasonable and customary basis and are generally subject to deductible and coinsurance. Servicesa re divied into three categories.
Employer Group Dental Plans
can be sold as individual and group plans provided by an employer. Employer group plans typically include preventative care for up to two visits or cleanings per year. Group dental plans do not contain conversion privileges but do allow for continuation of coverage under COBRA Rules
Omnibus Budget Reconciliation Act of 1990
congress passed a law that authorized the NAIC to develop a standardized model for Medicare Supplement Policies. Any agent selling a Medicare Supplement must make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
Medicare Part A Inpatient hospital care
covered for 90 days, for the first 60 days there is a one-time deductible of 1,100 and then Part A will cover all additional eligible medical services. On the 61st day through the 90th day the patient is responsible for an additional co-pay of 275 dollars per day. 90 day benefit period begins or resets when the patient has been out of the hospital for 60 days. LIfetime 60 day reserves can be used if a patient exceeds 90 days, and comes with an additional co pay of 550 dollars per day
Medicare Part A
covers most inpatient hospital care, inpatient home health care, hospice care, skilled nursing care and inpatient psychiatric care. In all cases part A only covers services that are medically necessary and deemed reasonable by Medicare
Spousal Impoverishment rule
deals with a situation where a spouse of a married couple requires nursing home care and the possibility that the institutionalized person's expenses would bankrupt the other spouse.
Disability Benefits
disabled worker is entitled to a monthly Social Security Disability Income benefit equal to the workers PIA at the time of the disability. The spouse benefit is the same as above and children under 18 would receive 50%. the waiting period is 5 months and the physical or mental impairment must be expected to last at least 12 months or result in an earlier death
Means Testing
each state establishes its own limits on income and financial resources in order to qualify for medicaid. The recipient must "spend down" or exhaust income, and their resources to a minimum amount before Medicaid becomes available. The recipient is allowed to keep a small monthly income and his/her home. When transferring assets the look-back period is 5 years and the home equity exemptions is 750,000 dollars
Medicaid
federal and state match funded system for people whose income and resouces are insufficient to meet the cost of necessary medical care. Operated by each individual state but administered through Central Medicaid Services. Its a program of healthcare provided to the needy, to be eligible a person must meet a means test to determine is the applicant is considered "poor." Once a person qualifies with low income and assets, person much also meet other requirements such as blind, disabled, pregnant, over 65, or caring for children receiving welfare. Federal government provides 56 cents for every dollar spent and states covers the balance.
Primary and Secondary Payor
federal laws extend primary coverage benefits to an employer's plan. In other words if an individual is working at age 65 in a company-sponsored plan with 20 or more employees, the employer is required to provide the same coverage offered to younger workers. the company plan will continue to be to be the primary coverage and Medicare will provide a secondary coverage. The employee does have the right to reject the company's plan as the primary payor and elect medicare, but the company can offer no incentives to influence the employee elect Medicare. IN group plans of 20 people or less, Medicare will provide the primary coverage and the employer's plan is secondary. If the insured has coverage under an employer sponsored plan while at the same time being insured by medicare, but the insured has end stage renal disease, the private plan is primary payor for up to a period of 30 months. After 30 months Medicare becomes the primary payor.
Restorative
fillings/crowns, treaments that restore function to natural teeth
Basic Services
fillings/oral surgery may require the insured to pay a deductible or 20% of the balance.
Medicare Part A exclusions
first three pints of blood, private room, telephone and television, and private duty nurse
Medicare Part B Medical Services and Supplies OUt patients only
flu shots and other preventative servies, ambulance, home dialysis, oral surgery, occupational and speech therapy, radiation treatment
Diagnostic/Preventative Services
generally provided without coinsurance or deductibles
Medicare
government provided universal health care for people age 65 or older enacted in 1965 as an amendment to the social security program. Some people under 65 may qualify including those who are collecting Social Security Disability Income for at least 2 years and those who have end stage renal disease or Lou Gehrig's disease
Open Enrollment Period
in Medicare Supplements it is the 6 month period that begins on the first day of the month in which the applicant turns 65 and is enrolled in Part B Medicare
Medicare Part A skilled nursing facility coverage
in order to qualify for skilled nursing care coverage not custodial care, the patient must be hospitalized for three consecutive days. The benefit period can never exceed 100 days. For the first 20 days of coverage, the patient is covered in full. On the 21st day, there is an additional co-pay of 137.50 per day, never to exceed the 100 day limit.
Replacement
in the event an applicant already has a policy in force, a notice of replacement must be signed by both the applicant and the agent at the time of application. This signed statement will notify or acknowledge that both parties are aware that this policy is intended to replace a policy already in force
Medicare Part A Inpatient Psychiatric Care
inpatient psychiatric care provides for a 190 day Lifetime Benefit
Medicare Part A Home Health Care Services and Hospice Care
intermittent nursing services, medical appliances, supplies including outpatient drugs for pain relief, home health aide, homemaker services, therapies, medical social services, respite care, and counseling. Both home health care and hospice care provide unlimited days of coverage under Medicare Part A
Deductibles and Coinsurance of Dental Plans
most dental plans have a deductible that must be met on an annual basis. Routine preventative care does not have deductibles
Medicare Part B
offers additional coverage for people who choose to purchase it in order to supplement the coverage in Part A. In summary part A covers room and board, while part b covers the other medical services. The coverage provided in Part B includes: physician services, diagnostic tests, physical and occupational therapy, medical supplies. Participants are required to pay a monthly premium of 96.40 and are responsible for an annual deductible of 155. After the deductible the policy has co-insurance of 80/20. Premiums for high income earners can also be higher based on means testing to help offset the cost of Medicare
Social Security
official name for Social Security is Old Age Survivors and Disability Income Act. provides a base of protection to all working americans against the financial problems associated with death, disability and aging. Although social security benefits help to offset these expenses, it does not replace the need for life insurance, retirement savings and disability insurance. It's funded through a payroll tax(FICA). It is a pay as you go system, meaning that the taxes paid by workers today are used to pay benefits today. As an individual earns income a portion is deducted and matched by the employer and deposited with Social Security in an account identified by a Social Security Number. When a worker's salary exceeds the taxable wage base in a calendar year, no more FICA tax is deducted from the salary for the remainder of the year. The account that is funded is known as the Primary Insurance Mount
Medicare Part B Unlimited Home Health Care
only if a person does qualify for Part A of Medicare
Medicare Part B Mental Illness
outpatient treatment with 50% co-payment
Medicare Part B Exclusions
private duty nurse, outpatient prescription drugs, custodial care, dental, physicals, immunizations, cosmetic surgery, eye glasses, hearing aids, and care received outside the united states.
Medicare Supplement Policies (Medigap)
provided by the private sector. Companies sell exactly the same coverage, but may charge different premium for exactly the same coverage because of loading and expense factors. The purpose of Medicare Supplement Policies, sometimes referred to as Medigap, is to supplement what Medicare doesn't pay. Applicant must be enrolled in both parts A and B to qualify
Tricare
regionally managed health care program for active duty and retired military personnel and their families, as well as survivors not eligible for medicare. Participant can choose from three plan options - Tricare Standard (free), Tricare Extra (PPO), Tricare Prime (Treatment at Military Facilities
Medicare Part B Physician & Surgeon's Services inPatient only
second surgical opinions, diagnostic tests, x-rays, medical supplies and medication in a doctor's office or hospital only, even if prescribed by a doctor.
Medicare Select
similar to an HMO in that the participant is restricted to a specific network of providers. It provides the same benefits as any Medigap policy but contains limitations as to doctors and hospitals that can be used, except in an emergency. The participants are entitled to change their minds within 12 months and change to a standard medigap policy.
Medicare Benefit Period
starts when a patient enters the hospital and ends when the patient has been out of the hospital for 60 days
Major Services
such as crowns and dentures, could have large deductibles or the insured must pay about 50% of the services provided
Prosthodontics
the replacement of missing teeth with artificial devises, such as bridgework or dentures
Blackout Period
time period when social security survivorship benefits cease from when the youngest child is 16 til surviving spouse turns 60.
Orthodontics
treatment of natural teeth to prevent and/or correct dental anomalies, such as braces or appliances
Oral Surgery
treatment of the mouth, such as extractions of teeth and related surgical treatment
Periodontics
treatment of the surrounding and supporting tissue of the teeth, such as treatment for gum disease
Survivorship Benefits
two survivor benefits payable by social security to a surviving spouse and dependent children. The first survivor benefit is a one-time lump sum $255 payable to the individuals widow, widower or funeral home, regardless of the amount on deposit in the individual's PIA. Additional benefit is paid to the surviving spouse or child. The eligible spouse of the deceased worker is entitled to a monthly life income equal to the workers PIA at death. A child under the age of 18 whose parent is deceased is eligible to receive a benefit equal to 75% of the workers PIA, although the child is entitled to receive benefits until age 18, there is a blackout period that occurs when no benefits are paid to the spouse. The time when the youngest child of the deceased worker attains the age of 16 and the spouse is not yet 60
Diagnostic and Preventative
type of care usually excluded from Medical Expense plans, most dental plans provide for routine preventative procedures such as teeth cleaning and fluoride treatments. Commonly, dental plans require periodic examinations as a requirement for continued coverage
Primary Insurance Amount
used to determine the benefits available to a social security participant. The PIA is the amount equal to the workers full retirement at age 67.
Dental Exclusions and Limitations
usually exclude elective procedures such as cosmetic procedures. To help keep costs down, policies provide for calendar year maximum benefits and lifetime benefits. Routine exams and cleanings are limited to once every six month
Retirement Benefits
workers eligible for full benefits will receive the benefit for life. A spouse benefit is equal to 50% of the retired worker's benefit. OASDI also allows for cost of living increases in retirement benefits in order to help seniors on fixed incomes cope with the cost of living increases over time.
