(4) - Social Insurance
How much is Part A Premium for 30-39 quarters?
$252
How much is Part A Premium for less than 30 quarters?
$458
For how many days of skilled nursing facility will Medicare pay benefits? (A) 30 (B) 60 (C) 90 (D) 100
*(D) 100* - Treatment in a skilled nursing facility is covered in full for the first 20 days. From days 21-100, the patient must pay the daily copayment. There are no Medicare benefits provided for treatment in a skilled nursing facility beyond 100 days. -
Benefit Period :
A period of time during which benefits are paid under the policy.
Waiting Period :
A period of time that must pass after a loss occurs before the insurer starts paying policy benefits.
Enrollee :
A person enrolled in a health insurance plan, and insured (doesn't include dependents of the insured).
Medicare Advantage (Part C) eligibility :
Beneficiaries must also be enrolled in Medicare Parts A and B.
Part D Medicare
Prescription drug coverage
Actual Charge :
The amount a physician or supplier actually bills for a particular service or supply.
Coinsurance :
The portion Medicare's approved amount that the beneficiary is responsible for paying.
Which of the following statements concerning Medicare Part B is correct? (A) It pays for physician services, diagnostic tests, and physical therapy. (B) It is provided automatically to anyone who qualifies for Part A. (C) It pays on a first dollar basis. (D) It pays 100% of Medicare's standards for reasonable charges.
*(A) It pays for physician services, diagnostic tests, and physical therapy.* - For those who have purchased the coverage, Part B pays 80% of out-patient medical cost after a deductible has been met. Part B covers physician and outpatient hospital services, and other medical and health services, such as diagnostic tests, and physical therapy -
The part of Medicare that helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care, is known as (A) Part A (B) Part B (C) Part C (D) Part D
*(A) Part A* - Medicare Part A pays for these services, subject to copayments and limitations on the number of days of care. -
What is the amount a physician or supplier bills for a particular service or supply? (A) Approved amount (B) Actual Charge (C) Assignment (D) Coinsurance
*(B) Actual Charge* - Actual charge is the amount a physician or supplier bills for a particular service or supply -
All of the following statements about Medicare Part B are correct EXCEPT (A) It is financed by tax revenues. (B) It is a compulsory program. (C) It covers services and supplies not covered by Part A. (D) It is financed by monthly premium.
*(B) It is a compulsory program.* - Part B is elective. Individuals become eligible for Part B at the same time they become eligible for Part A, however Part B requires that a monthly premium be paid. -
Which of the following programs is made up of 4 parts, where the first part is paid for by FICA, and the second is financed by premiums and payroll taxes? (A) Medicaid (B) Medicare (C) Blue Cross (D) Blue Shield
*(B) Medicare * - Medicare has four parts: A, B, C, and D. Part A, Hospital insurance, is financed through portion of the payroll tax (FICA). Part B, Medical Insurance, is financed from monthly premiums paid by insureds and from the general revenues of the federal govt. Part C allows people to receive all of their health care services through available provider organizations, and Part D is for prescription drug coverage. -
If one takes Social Security retirement benefits at age 62, what needs to be done at age 65 to qualify for Medicare? (A) Apply at a local Social Security office. (B) Nothing. (C) Apply for coverage through state. (D) Appear for a physical at the Social Security office.
*(B) Nothing.* - Nothing needs to be done in this case. Medicare Part A and B will automatically be effective the month you turn 65. *
Medicare Part A services do NOT include which of the following? (A) Hospice Care (B) Outpatient Hospital Treatment (C) Post hospital Skilled Nursing Facility Care (D) Hospitalization
*(B) Outpatient Hospital Treatment* - Covered under PART B -
In order for an insured under Medicare Part A to receive benefits for care in a skilled nursing facility, which of the following conditions must be met? (A) The insured must over daily copayments. (B) The insured must first been hospitalized for 3 consecutive days. (C) The insured must have a medicare supplement insurance policy. (D) There is no benefit provided under Medicare Part A for skilled nursing care.
*(B) The insured must first been hospitalized for 3 consecutive days.*
Which of the following statements is INCORRECT concerning Medicare Part B coverage? (A) It is a voluntary program designed to provide supplementary Medical insurance to cover physician services and supplies not covered under Part A. (B) Part B coverage is provided free of charge when an individual turns age 65. (C) Participants under Part B are responsible for an annual deductible. (D) Part B will pay 80% of covered expenses, subject to Medicare's standards for reasonable charges.
*(B). Part B coverage is provided free of charge when an individual turns age 65.* - Those who desire Part B coverage must enroll and pay a monthly premium. -
Which of the following must the patient pay under Medicare Part B? (A) All reasonable charges above the deductible according to Medicare standards. (B) A per benefit deductible. (C) 20% of covered charges above the deductible. (D) 80% of covered charges above the deductible.
*(C) As established by Medicare, the patient must pay 20% of covered charges above the deductible.*
What is the difference between the Medicare approved amount for a service or supply and the actual charge? (A) Limiting charge (B) Coinsurance (C) Excess charge (D) Actual charge
*(C) Excess charge* - Excess charge is the difference between the Medicare approved amount for a service or supply and the actual charge. -
Which of the following statements is CORRECT concerning the relationship between Medicare and HMOs? (A) Medicare Advantage is Medicare provided by an approved HMO only. (B) All HMOs and PPOs charge premiums beyond what is paid by Medicare. (C) HMOs may pay for services not covered by Medicare. (D) HMOs do not pay for services covered by Medicare.
*(C) HMOs may pay for services not covered by Medicare. * - The advantages of an HMO or PPO for a Medicare recipient may be that there are no claims forms required, almost any medical problem is covered for a set fee so health care costs can be budgeted, and the HMO or PPO may pay for services not usually covered by Medicare or Medicare supplement policies, such as prescriptions, eye exams, hearing aids, or dental care. -
Which of the following statements is NOT correct regarding Medicare? (A) Medicare Part A provides hospital care. (B) Medicare Part B provides physician services. (C) Medicare Advantage must be provided through HMOs. (D) Medicare Advantage may include prescription drug coverage at no cost.
*(C) Medicare Advantage must be provided through HMOs.* - Medicare Part A provides hospital care; Medicare Part B provides doctors and physician services, and Medicare Advantage (previously Medicare+Choice) offers expanded benefits for a fee through private health insurance programs such as HMOs and PPOs. -
How long is an open enrollment period for Medicare supplement policies? (A) 1 year (B) 30 days (C) 90 days (D) 6 months
*(D) 6 months * - An OE period is a 6-month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare Part B. -
All of the following individuals may qualify for Medicare health insurance benefits EXCEPT (A) A healthy person age 65. (B) A person age 45 who has permanent kidney failure. (C) A person under age 65 who is receiving Social Security disability benefits. (D) A retired person age 50.
*(D) A retired person age 50.* - Under current federal laws, any of the described persons could qualify for Medicare, except individuals under age 65 who have no special circumstances. -
Concerning Medicare Part B, which statement is INCORRECT? (A) It is known as medical insurance. (B) It offers limited prescription drug coverage. (C) It provides partial coverage for medical expenses not fully covered by Part A. (D) It is fully funded by Social Security taxes (FICA).
*(D) It is fully funded by Social Security taxes (FICA)* - Part B i funded by monthly premiums and from the general revenues of the federal govt. -
Which type of care is NOT covered by Medicare? (A) Hospice (B) Respite (C) Hospital (D) Long-term care
*(D) Long-term care* - Hospice care, which includes respite care, and hospital care are all included in Medicare Part A -
All of the following are covered by Part A of medicare EXEPT (A) In-patient hospital services (B) Post-hospital nursing care (C) Home health services (D) Physician's and surgeon's services
*(D) Physician's and surgeon's services* - Covered under PART B -
Who else can obtain Medicare?
- People entitled to Social Security disability income benefits for 2 years - Has a permanent kidney failure
Three Options for signing up or Medicare Part A :
1 - Initial Enrollment period - 3 months before turning 68, ending 3 months after 65th birthday. 2 - General Enrollment period - Between Jan 1st and March 31st each year. 3 - Special Enrollment period - Anytime during the year if the individual or their spouse is still employed and covered under a group health plan.
How long is the free-look period for Medigap?
30 days - Allowed to be returned for a full refund of the premium paid
How long is the wait until benefits are paid under Social Security?
5 months
What is the OE period for Medigap?
6-months, once they first sign up for Medicare Part B. Applicant must generally have both Medicare Part A and Part B.
When does a new benefit period and new deductible begin for Part A?
60 non-use days
Medicare Part B pays for medical services in or out of the hospital (%?)
80% of approved amount after deductible
Medicare :
A federal medical expense insurance program for people age 65 and older even if the individual continues to work.
Part C Medicare
Allows people to receive all their health care services through available provider organizations
Approved Amount :
Amount Medicare determines to be reasonable for a service that is covered under PART B MEDICARE
Credits needed to qualify for disability benefits under Social Security
Before age 24 : 6 credits 24-31 : Persons can qualify for benefits with only 6 credits for having worked half of the time between 21 and start of the disability 31-42 : 20 credits 44 : 22 credits 46: 24 credits 48 : 26 credits 50 : 28 credits 52 : 30 credits 54 32 credits 56 : 34 credits 58 : 36 credits 60 : 38 credits 62+ : 40 credits
Ambulatory Surgical Services :
Care that is provided at an ambulatory center. -- These are surgical services performed at a center that DO NOT require a hospital stay unlike inpatient hospital surgery.
Pre-Existing Conditions :
Conditions for which the insured has received diagnosis, advice, care, or treatment during a specific time period prior to the application for health coverage.
Omnibus Budget Reconciliation Act of 1990 (OBRA) :
Congress passed a law that authorized the NAIC to develop a standardized model for Medicare supplement policies. This model requires Medigap plans to meet certain requirements as to participant eligibility and the benefits provided. Provides consumers with a degree of protection and to standardize the protection afforded.
What are persons who apply for Social Security Benefits referred to state agencies?
Disability Determination Services (DDS) to evaluate the disability.
What does Social Security benefits provide?
Disability income benefits for those who qualify. Also referred to as Old Age, and Disability Insurance (OASDI).
What does Medicare Part B pay for?
Doctor services and supplies that are not covered by hospital insurance.
Participating Doctor or Suppliers :
Doctors and suppliers who sign agreements to become Medicare-participating. For example, they have agreed in advance to accept assignment on all Medicare claims.
Nonparticipating :
Doctors or suppliers who may choose whether or not to accept assignment on each individual claim.
Whom is Part B offered to?
Everyone who enrolls in Part A.
True or False: Part C plans have higher out-of-pocket costs than Original Medicare.
False - Part C plans may have lower out-of-pocket costs. They also offer extra coverage such as vision, hearing, dental, and other health and wellness programs.
Truth or False: Those who sign up for the standard Prescription Drug Benefit will NOT have a monthly premium or deductible.
False- Monthly premium varies by plan.
True or False: Medicare is primary coverage and employer plans are secondary.
False- Vise versa.
Part B Medicare
Financed from monthly premiums paid by insureds and from the general revenues of the federal govt.
Part A Medicare
Financed through portion of the payroll tax (FICA)
How many days does Part A help pay for Skilled Nursing Facility Care?
First 20 days paid for Days 21-100 all but daily deductible Nothing past 100 days
How many days does Part A help pay for Inpatient Hospital Care coverage?
First 60 days all but deductible Days 61-90 all but daily deductible After day 90 (up to 60 says) all but daily deductible After lifetime reserve says nothing
Social Security Disability Insured Status :
Fully insured or currently insured, depending on the number of coverage credit earned.
Peer Review Organization (PRO) :
Groups of practicing doctors and other health care professionals who are paid by the govt to review the care given to Medicare Patients.
All Medigap policies are...
Guaranteed renewable - Insurance company cannot cancel or nonrenew coverage except for nonpayment of the premium or because of material misrepresentation on the app
Who must approve Medicare SELECT policies?
Head of a state's department of insurance.
How is income calculated for eligible groups of Medicaid?
In relation to a percentage of the Federal Poverty Level (FPL).
Disability :
Inability to engage in any gainful work that exists in the national economy. The disability must result from a medically determinable physical or mental impairment that is expected to result in early death, or has lasted or is expected to last for a continuous period of 12 months.
Who designs and administrates Medicaid?
Individual states, typically through the state's Department of Public Welfare, under broad guidelines established by the federal govt.
What does Medicare Part A help pay for?
Inpatient Hospital Care Inpatient Care in a skilled Nursing Facility Home Health Care Hospice Care
Services that are not fully covered by Medicare will get coverage from _______________.
Medicaid
Durable Medical Equipment :
Medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home.
Outpatient Physical and Occupational Therapy and Speech Pathology Services :
Medically necessary outpatient physical and occupational therapy or speech pathology services prescribed by a doctor or therapist.
Medicare SELECT :
Medicare supplement policy that contains restricted network provisions -- provisions that condition the payment of benefits, in whole or in part, on the use of network providers. Essentially operates like an HMO.
What are Medicare Supplement plans referred to as?
Medigap - Policies issued by private insurance companies that are designed to fill in some of the gaps of Medicare. Are sold and serviced by private insurers and HMOs.
What happens if individuals fail to sign up for Part A when first eligible?
Monthly premium may go up 10% (unless for special enrollment).
How is Part B funded?
Monthly premiums and from the general revenues of the fed govt.
"Donut hole" :
Most medicare drug plans have a coverage gap, also called "donut hole". Coverage gap begins after beneficiary and the drug plan have spent a certain amount for covered drugs. Beneficiary is responsible for 25% of brand name prescription drug costs, and 25% of the plan's cost for covered generic drugs. as of 2020, the donut hole for generic drugs has closed.
Prescription Drugs (limited coverage) :
Only medicines that are administrated in a hospital outpatient department under certain circumstances are covered. Under Part B - insured pays 100% for most prescription drugs Under Part D - covers For Ex.) Injected drugs at doctor's office, some oral cancer drugs, or drugs that require durable medical equipment(nebulizer or infusion pump).
Carriers :
Organizations that process claims that are submitted by doctors and suppliers.
Intermediaries :
Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services.
Comprehensive Outpatient Rehabilitation Facility (CORF) :
Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.
What does the term Original Medicare refer to?
Part A (Hospital Insurance) Part B (Medical Insurance Only) ---- Usually does not cover prescription drugs
What are the 4 parts of Medicare?
Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Part D: Prescription Drugs
Out Patient Hospital Services :
Part B covers outpatient hospital services received for diagnosis and treatment, such as care in an emergency room, outpatient clinic, or a hospital.
Part D :
Part D - Prescription Drug Benefit This optional coverage is provided through private prescription drug plans (PDPs) that contract with Medicare. To receive benefits, beneficiaries must sign up with a plan offering this coverage in their area and must be enrolled in Medicare Part A or in Parts A and B. In areas where no private plans are offered, the govt. will offer a standard plan. Medicaid recipients are automatically enrolled.
Assignment :
Physician or a medical supplier agrees to accept the Medicare-approved amount as a full payment for the covered services
Medical insurance under Part B of Medicare DOES NOT cover the following :
Private duty nursing Skilled nursing home care costs over 100 days per benefit period Intermediate nursing home care Physician charges above Medicare's approved amount Most outpatient prescription drugs Care received outside the US Custodial care received in home Dental Care, cosmetic care, eyeglasses, hearing aids, orthopedic shoes, acupuncture expenses Expenses incurred due to a war or act of war
Under the inpatient hospital stay, what does Part A NOT include?
Private duty nursing TV or Phone in room Private Room (unless medically necessary)
Pap Smear Screening :
Provides for a pap smear to screen for cervical cancer once evert 2 years.
(Part C) Special Needs Plans :
Provides more focused and specialized health care for specific groups of people.
Medicare supplemental plans coverage is offered on a guaranteed issue basis. An insurance company must do the following...
Sell the patient a Medicare supplemental policy Cover all pre-existing conditions incurred more then 6 months from effective date of coverage Not charge more for a supplement policy because of part or present health problems
Who is Medicare administered by?
The Center for Medicare and Medicaid Services (CMS)
What changed the name of Part C from Medicare+Choice to Medicare Advantage?
The Medicare Modernization Act of 2003.
What act implemented Part D to be added?
The Medicare Prescription Improvement , and Modernization Act of 2003 (MMA), which was passed Nov 2003.
What do most people enrolled in Medicare Part B pay?
The Standard Monthly Premium - If an insured's modified adjusted gross income reported on IRS tax return is above a certain amount, the insured may be required to pay a higher premium -
Deductible :
The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.
Excess Charge :
The difference between the Medicare approved amount for a service or supply and the actual charge.
Limiting Charge :
The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment of the Medicare approved amount.
Premium :
The money paid to the insurance company for the insurance coverage.
What determines the disability benefit?
The person's Primary Insurance Amount (PIA). PIA is based on the person's average indexed earnings on which Social Security taxes have been paid.
What happens if Medicare beneficiaries do not enroll in Part D when first eligible?
They must pay a 1% penalty for each month they delayed enrollment.
True or False : When you become eligible for Part A, you are told that you will get and have to pay for Part B.
True - Unless it is declined. If it is decided later you want it, after declining it, one must wait until the next general enrollment period (Jan 1 - Mar 31) to enroll.
True or False: Medicare Advantage is Medicare provided by an approved HMO or PPO.
True- Many HMO's or PPO's do not charge premiums beyond what is paid by Medicare. May also pay for services not usually covered by Medicare or Medicare supplement polices such as prescriptions, eye exams, hearing aids, or dental care.
True or False: Once the beneficiary has met the plan's out-of-pocket cost requirements for the year, catastrophic coverage begins automatically.
True- This coverage will cover 95% of prescription drug costs.
When are monthly Part A premiums required?
When a beneficiary is not "fully insured" under Social Security -- Have not earned 40 quarters of coverage (10 years of work).
When do Social Security benefits cease?
When individual's retirement benefits start, when individual dies, or is no longer disabled. At death, family benefits will continue as survivor benefits. Benefits will continue for an adjustment period of 3 months if an individual no longer satisfies the definition of disability.
