Medicare 101

What is the annual deductible for all Medicare Part B beneficiaries in 2020?

$198

David is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and David would like to join that plan. What should you tell him?

SNP plans limit enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP.

Mrs. Sanchez is 66 years old, and has coverage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her?

She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires.

Steven is trying to understand the difference between Original Medicare and Medicare Advantage. Explain the difference to Steven in your own words?

Simply put, Original Medicare has Part A and Part B, Part D can be added, and Supplemental coverage can also be added. Medicare Advantage has Parts A, B, and D in most cases with extra benefits and lower out of pocket costs.

Medicare home health care is:

Skilled care and home health aide services provided at home to treat an illness or injury.

Select all items covered by Medicare Part A

Some Health Care, Blood, Skilled Nursing Facility, Inpatient mental health

When a beneficiary leaves employer coverage, this makes them eligible for what type of election period?

Special Election Period

How is Medicare's Hospital Value-Based Purchasing Program funded?

The Hospital VBP Program is funded by percentage withheld from participating hospitals Diagnosis-Related Group (DRG) payment

If you join During one of the 3 months before you turn 65, coverage begins

The first day of the month you turn 65

What does it mean if a provider "takes assignment?"

The provider agrees to accept Medicare, but can charge you up to a 35 percent coinsurance for services.

What is Original Medicare?

The traditional fee-for-service program offered directly through the federal government.

As a result of the Affordable Care Act, Medicare beneficiaries can access many preventive care benefits without without cost sharing under the Medicare program.

True

If you buy a Medigap policy during the six-month Medigap open enrollment period you can't be denied Medigap coverage or be charged more for a past medical condition.

True

If you don't enroll in Part B coverage during your initial enrollment period and aren't covered through an employer plan, you risk being locked out of primary medical coverage and will likely owe higher Part B premiums for as long as you have Medicare.

True

If you or your spouse have not paid into the Social Security payroll taxes for at least 40 quarters, you generally are not eligible for premium-free Medicare Part A.

True

If you're not receiving Social Security benefits when you become eligible for Medicare, you will not be automatically enrolled in Medicare health coverage and must apply for it yourself.

True

Medicare began issuing a new style of identification cards in April 2018. Using a unique identification number, instead of the beneficiary's social security number.

True

Medicare consists of both Parts A & B

True

Medicare covered days 91-150 are called "lifetime reserve days" and can only be used once.

True

Medicare covers most hospice care with little expense to patients.

True

Medicare covers preventive services such as testing for prostate cancer, flu and pneumonia shots, mammograms, and bone density scans.

True

Medicare supplement insurance and Medigap coverage are the same thing.

True

Ronald is disabled and has Medicare. He is not yet 65 years old. He turned down Part B and now facing a Part B premium penalty. Ronald will unfortunately be stuck with the Part B premium penalty for the rest of his life, provided that he does not qualify for any assistance programs.

True

How many Medicare claims for physician, hospital and other services are paid every year?

About one billion

What share of the total Medicare population is enrolled in a Medicare Advantage plan, such as a Medicare HMO or PPO, instead of the traditional Medicare program?

About one third

Jorge is 49 years old, but 18 months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?

After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.

Which groups of people are covered by Medicare?

All of above [People aged 65 and older, people under age 65 with a long-term disability who have received social security disability insurance payments for at least two years, people with amyotrophic lateral sclerosis (ALS) which is also known as Lou Gehrig's disease, and people with end-stage renal disease (ESND)]

Nursing home quality standards were improved by Congress in 1987 as a result of:

All of the above (An Institute of Medicine study calling for enhanced Federal standards, concern about mentally ill individuals not receiving active treatment, and excessive use of physical and chemical restraints in nursing home patients)

Which of the following services is not typically covered by Medicare?

All of the above (Hearing aids, dental services, long-term care services and supports, and eye exams and glasses)

Which President thought that health maintenance organizations (HMOs) would help contain the growth in health care spending?

All of the above (President Nixon, President Reagan, and President Clinton)

By law, Original Medicare must cover your health care expenses while you're traveling outside the United States and its territories.

False

Generally, people must actively enroll in Extra Help if they have Medicaid and Medicare.

False

Individuals need to have a certain income in order to be eligible for Medicare.

False

Medicare beneficiaries have to select a primary care physician or get a referral to see a specialist

False

Medicare doesn't include coverage of wheelchairs and walkers.

False

Medicare supplement insurance (Medigap) pays for some of the things Medicare Advantage (Part C) plans don't cover.

False

Medicare's home health care benefit will cover all skilled nursing and home health aide care expenses.

False

Once you enroll in Medicare, you must give up any other health care coverage you have.

False

Original Medicare (Parts A and B) is premium free. Medicare Advantage (Part C) and Part D prescription drug plans are optional—you need to buy them.

False

Social Security and Medicare are actually the same thing. False True

False

Where you live doesn't matter. All Medicare Part C and Part D plans are offered by the federal government, so coverage is the same nationwide.

False

You can enroll in Medicare without penalty anytime after you turn 65.

False

You cannot have both Medicare and Medicaid.

False

Which enrollment period potentially carries a premium penalty for Medicare Part B? Special enrollment period General enrollment period None of the above; Part B does not have a penalty Initial enrollment period

General enrollment period

What plan has a preferred group of doctors and hospitals ('network') provide your healthcare, while a Primary Care Physician (PCP) manages your care and refers you to specialists as needed? Hint: These types of plans may have more benefits and lower out-of-pockets costs.

HMO

Inpatient hospital care includes

meals, treatment drugs, semi permanent room

Mr. Jones is disabled, 62 years old and works for a company that has 80 employees. He has both Original Medicare and insurance from his employer. Mr. Jones needs medical care. Generally,

His current employer insurance should pay first on any medical care he receives and Medicare should pay second.

Ms. K is asked to leave the hospital where she has been staying, but feels that she is not well enough to do so. Ms. K should request an immediate review of the hospital's decision to discharge her by contacting this organization:

Hospital Quality Center

Which part(s) of Medicare will usually provide coverage for immunosuppressant drugs?

Part B

Medicare Advantage is also referred to as Medicare Part ?

Part C

What share of Medicare beneficiaries lived on incomes of less than $26,200 in 2016, including income from Social Security and all other sources?

50%

During the Initial Coverage Election Period (ICEP), the member has ____ months to enroll in coverage with a Medicare Advantage plan.

7

Which of the following statements most accurately describes a transition fill?

A policy that allows new members of Part D plans to get temporary coverage of medications they were already taking.

What Federal Agency oversees Medicare for the US?

CMS

Health care entities must meet these standards in order to participate in the Medicare program. These standards establish the health and safety foundation to improving quality and care given to Medicare beneficiaries.

Conditions of Participation

Which program under traditional Medicare does NOT have the monthly cost increased by an income-related monthly adjustment amount for individuals whose income exceeds certain thresholds?

Medicare Part A - Hospital Insurance

Jennifer has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Jennifer?

Medicare Part B helps cover medically-necessary services like doctors' services and tests, outpatient care, home health services, durable medical equipment, and other medical services. Part B also covers some preventive services. Medicare Part B is optional, but in some ways, it can feel mandatory, because there are penalties associated with delayed enrollment. As discussed later, you don't have to enroll in Part B, particularly if you're still working when you reach age 65. ... You have a seven-month initial period to enroll in Medicare Part B.

This type of secondary coverage to Medicare is often referred to as a Medigap coverage.

Medicare Supplement

Matthew has several family members who have died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?

Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of disease. Matthew will need to check specific tests before obtaining them to see if they will be covered.

Marie wears glasses and dentures and has been visiting an acupuncturist for her arthritis. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?

Medicare does not cover acupuncture, or, in general, glasses or dentures.

Shawn is concerned that if he signs up for a Medicare health plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern?

Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.

Approximately what share of the federal budget goes toward Medicare? 50% 25% 15% 5%

15%

In what year did HMO's begin their participation in the Medicare program?

1966

Americans younger that 65 with the following diagnoses are allowed to enroll in Medicare upon diagnosis of the disease.

Amyotrophic Lateral Sclerosis

Which category of health expense is generally not covered by Medicare?

Custodial Care

In the Medicare program, what does DRG stand for?

Diagnosis-Related Group

Not available in all areas, this plan feature benefits tailored for people with a full Medicaid and Medicare. These plans also have a Special Enrollment Period.

Dual eligible special needs plans (D-SNPs)

Sergio wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Advantage Plan before he starts looking at specific plans. What could you tell him

I would inform Sergio that Original Medicare includes part A (hospital) and B (medical) and possibly joining a separate medical drug plan; whereas, Medicare Advantage is an all in one that includes Parts A, B, and D usually. Original Medicare helps pay out of pocket costs (like 20% coinsurance) and helps shop for + buy supplemental coverage; whereas, Medicare Advantage has lower out of pocket costs. Original Medicare allows members to use any doctor or hospital that takes Medicare anywhere within the United States; whereas, Medicare Advantage requires member to use doctors in the plan's network in many cases. Medicare Advantage also offers extra benefits that Original Medicare does not include, like: vision, hearing, dental, and more. Simply put, Original Medicare has Part A and Part B, Part D can be added, and Supplemental coverage can also be added. Medicare Advantage has Parts A, B, and D in most cases with extra benefits and lower out of pocket costs.

Greg is considering a Medicare Advantage HMO and had questions about his ability to access providers. What should you tell him?

In most Medicare Advantage HMOs, Greg must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency).

Juanita believes that she will qualify for Medicare coverage when she turns 65, without laying any premiums, because she had been working for 40 years and paying Medicare taxes. What should you tell her?

In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.

The election period a beneficiary is entitled to when they are turning 65 is called _______, *

Initial Coverage Election Period

Melanie needs more than 100 days of skilled nursing facility care Problem: Melanie has Original Medicare. She broke her hip in a biking accident and spent three days as a hospital inpatient before being admitted to a skilled nursing facility (SNF). Melanie spent 100 days in the SNF, at which point she was discharged because she ran out of Medicare-covered days in her benefit period. Three weeks later, she broke her leg in another accident and was admitted as a hospital inpatient for five days. After five days, her doctor told her that she should be transferred to a SNF to receive rehabilitation care. Question: Will Medicare cover Melanie's SNF stay for the second accident after she is discharged from the hospital?

Medicare will not cover additional days of SNF care as Melanie has used up all of her 100 Medicare-covered SNF days in her benefit period. SNF care is covered by Medicare Part A. Medicare covers up to 100 days of care at a SNF during each benefit period (days 1-20 in a benefit period are covered in full by Medicare; days 21-100 are covered with a $185.50 per day in 2021).

Eugenia will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under Part A because she was not born in the United States. What should you tell her?

Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums.

Mr. Fernandez continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him?

Mr. Fernandez will not have a penalty since he had creditable coverage.

Mrs. Heathers is turning 65 in November and ask you if there are any special eligibility requirements for Medicare Advantage . What should you tell her?

Must have Medicare Part A and B, No ESRD, lives in the service area

A prescription drug benefit, Part D, was added to Medicare in 2006. Do all Medicare beneficiaries automatically receive the drug benefit when their Medicare coverage begins?

No, Part D drug coverage does not begin automatically for all Medicare beneficiaries when they sign up for Medicare

Most large employer health plans protect enrollees from extraordinarily high medical bills by placing an annual limit on out-of-pocket costs. Does the traditional Medicare program do this? No, traditional Medicare does not include an out-of-pocket limit Yes, traditional Medicare does include an out-of-pocket limit

No, traditional Medicare does not include an out-of-pocket limit

Kevin has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program?

Not all Medicare Advantage Plans work the same way. Before you join, take the time to find and compare Medicare health plans in your area. Once you understand the plan's rules and costs, here's how to join: Use Medicare's Plan Finder. Visit the plan's website to see if you can join online. Fill out a paper enrollment form. Contact the plan to get an enrollment form, fill it out, and return it to the plan. All plans must offer this option. Call the plan you want to join. Get your plan's contact information. Call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. When you join a Medicare Advantage Plan, you'll have to give these: Your Medicare number The date your Part A and/or Part B coverage started

Samantha is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage. What should you tell her?

Not all Medicare Advantage Plans work the same way. Before you join, you can find and compare Medicare health plans in your area by visiting Medicare.gov/plan-compare. Once you understand the plan's rules and costs, use one of these ways to join: • Visit Medicare.gov/plan-compare and search by ZIP code to find a plan. You can also log in for personalized results. If you have questions about a particular plan, select "Plan Details" to get the plan's contact information. • Visit the plan's website to see if you can join online. • Fill out a paper enrollment form. Contact the plan to get an enrollment form, fill it out, and return it to the plan. All plans must offer this option. • Call the plan you want to join. Visit Medicare.gov/plan-compare to get your plan's contact information. • Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. When you join a Medicare Advantage Plan, you'll have to provide this information from your Medicare card: • Your Medicare Number • The date your Part A and/or Part B coverage started. Remember, when you enroll in a Medicare Advantage Plan, in most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. For some services, you may be asked to show your red, white, and blue Medicare card.

The Annual enrollment period for Medicare takes place from _____________ each year.

October 15 - December 7

This period of time allows beneficiaries to make a one time change to another MA plan or original Medicare.

Open enrollment period

Medicare Part B benefits include, but are not limited to (Select all that Apply)

Outpatient mental health, durable medical supplies, doctor's services, emergency room services

Similar to an HMO, in this plan, you have a preferred group of doctors, specialists and hospitals ('network'). However, you do not need a referral to see a specialist. You may use providers outside the preferred network but your costs may be higher.

PPO

Which part of original Medicare covers hospitalizations?

Part A

Medicare Part A is primarily financed through:

Payroll taxes

Tony is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?

Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs.

Which of the following statements is true?

VA benefits do not coordinate with Medicare.

Natasha does not have enough work history to qualify for premium-free Medicare Part A Problem: Natasha is turning 65 in a few months and wants to enroll in Medicare because she has no other insurance. She has never worked in the U.S. and is worried about the costs. She knows that people who have fewer than 10 years of work history in the U.S. may owe a premium for Part A. Her husband Eric is 58 and has worked in the U.S. for over 25 years. Question: Is Natasha eligible to enroll in Medicare when she turns 65? Will she qualify for premium-free Part A?

Yes, Natasha is eligible to enroll in Medicare when she turns 65. She can enroll starting three months before she turns 65, the beginning of her Initial Enrollment Period. Although work history does not affect someone's eligibility for Medicare, it does affect how much someone pays for the Part A premium. Based on her own work history, Natasha does not qualify for premium-free Part A. However, she can use Eric's work history to qualify for premium-free Part A once he is eligible for Social Security benefits. Eric will be eligible for Social Security benefits when he turns 62 or becomes eligible to receive Social Security Disability Insurance (SSDI). Until then, Natasha will owe a premium for Part A.

Steven did not sign up for Medicare when he was first eligible Problem: Steven turned 65 three years ago and decided to not enroll in Medicare Part B during his Initial Enrollment Period (IEP) because he was covered by his employer's health insurance. He is 68 now and is retiring from his job at the end of the month. As a result, he is losing his coverage through his employer and wants to enroll in Part B. He had read that enrolling late in Part B will result in coverage gaps and penalties. Question: Can Steven enroll in Part B? Will he have to pay a late enrollment penalty (LEP) and face gaps in coverage?

Yes, Steven can enroll in Part B. He will not have to pay a late enrollment penalty or face gaps in coverage. Steven has a Special Enrollment Period (SEP). SEPs are periods of time outside of normal enrollment periods that are triggered by specific circumstances. In Steven's case, he is eligible for a Part B SEP.

Mrs. P, a New Yorker, has decided to buy Medigap Plan C to help cover some of her costs. She has found two companies in her area that offer this plan. One costs $150 a month and the other costs $185 a month. If she is mainly concerned about costs, should she buy the cheaper one?

Yes, the cheaper one offers the same benefits as the more expensive one.

Which of the statements is true?

You must buy a separate prescription drug plan with Original Medicare, whereas some Medicare Advantage plans offer drug coverage.