Social Insurance- Social Security Benefits & Medicare

Occupational

If an insured is injured while working, workers compensation will pay for the medical expenses incurred. The individual's group policy will not pay if injury is covered under workers compensation. Most (although some do) individual policies do not pay benefits if covered by workers compensation.

Requirements for retirement benefits

If born in 1929 or later, an individual needs 40 coverage credits/quarters to qualify for retirement benefits. In 2007, one quarter of coverage is credited for every $1,000 in earnings during the year. You may accumulate up to 4 quarters of coverage a year.

Dependent Children Benefits

In Wisconsin, dependent children must be covered from the MOMENT OF BIRTH.

Medicare Advantage Private Fee-For-Service Plan- (PFFS)

Under this plan, you are allowed to go to any doctor, hospital, or health provider that agrees to accept the PFFS plan's term of payment. The PFFS plans do not have contracts with doctors, hospitals, or heath care providers. You do not have to have a referral from the plan for medical treatment.

Supplemental Security Income Disability (SSI)

A person may receive disability income benefits that have low incomes and few resources and are: - Age 65 or older - Blind -Disabled A. Single individual has a worth up to $2,000 in cash, checking, savings, stocks and bonds, certificates of deposits, or a Christmas club. B. Couple may own as much as $3,000.

Owner's Rights

A person who owns a policy, the insured, has certain rights and privileges under that policy. These rights are to: A. Cancel, void, or lapse coverage B. Reinstate the policy and its coverage C. Change the premium paying frequency D. Change benefit levels E. Change beneficiaries F. Assign the policy to others

Non-Occupational

A policy that will pay benefits only when the individual is injured AWAY from work.

Taxation of Social Security Retirement Benefits

A select group of people will have to pay taxes on Social Security benefits received. This affects people in high income brackets.

Post hospital Skilled Nursing Care

Must be in the hospital at least 3 days and enter a skilled nursing facility within 30 days of leaving the hospital, and is certified as medically necessary. Benefit: Provides up to 100 days of coverage. The first 20 days Medicare pays for everything. The next 80 days the recipient pays $124 a day (2007) with Medicare paying the balance. After 100 days, the Medicare recipient pays for all expenses. Blood: While hospitalized, Medicare Part A pays for all but the first 3 pints of blood.

Hospital and Ambulatory Surgery Center Charges and Anesthetics for Dental Care

Must cover hospital or ambulatory surgery center charges incurred and anesthetics provided in conjunction with dental care for an individual with a chronic disability or an individual with a medical condition that requires hospitalization or general anesthesia for dental care.

Wisconsin Medicare Supplement Insurance Policies (MEDIGAP)

Nationally, there are 12 Medicare supplement policies that may be sold. Each of the 12 policies must provide standard levels of coverage. WISCONSIN HAS RECEIVED A WAIVER AND ONLY ONE MEDICARE SUPPLEMENT POLICY MAY BE SOLD. Wisconsin supplement policies must have a standard core of coverage with riders that are available. Medicare supplements are the preferred term in Wisconsin, nationally they are called, "Medigap " policies.

Home Health Services

Part-time or intermittent skilled nursing care, physical therapy, medical social services, medical supplies, and some rehabilitation equipment, may be paid in full when you are confined at home. This applies as long as these services are prescribed by a doctor. Other Benefits: Hospice Care and Psychiatric Care

Medicaid provides coverage for:

Physician services, inpatient and outpatient hospital care, prescription and over-the-counter drugs, Vision, including eyeglasses, physicals, prenatal services, laboratory and x-ray services, substance abuse, hearing services, including hearing aids, mental health and day treatment, therapy-speech, physical, occupational, nurse-midwife services, skilled nursing home, dental services, medical supplies and equipment, private duty nursing care, vaccines for children, family planning services, hospice care, hospital care, transportation of medical services, personal and home health care. - To determine if you are eligible for Medicaid, you must release information about your assets, such as cash, stocks, bank accounts, certain types of life insurance, a home and other buildings, and land.

Part B Medical Insurance

Premium: $93.50 a month (2007), for most people with income under $80,000. Premium increases with income levels. Covers: Eligible expenses for physicians' services, inpatient and outpatient Outpatient Medicare services and supplies at a hospital Physical, occupational, and speech therapy Outpatient psychiatric care Home health care (if enrolled in Part B only) Ambulance, diagnostic test, x-rays, braces limbs, back, or neck Drugs that are not self-administered Non-routine vision services Necessary ambulance services Rental of durable medical equipment used in the home, including oxygen tanks, hospital beds, and wheelchairs Artificial replacements for parts of the body Colostomy bags and supplies Flu shots and pneumococcal vaccine Surgical dressings, splints, casts, and similar medical supplies that have been requested by a doctor. Benefits: Medicare recipient pays annual deductible of ($131, 2007) Medicare recipient pays 20% of approved charges Medicare pays 80% of approved charges Unapproved Medicare charges are paid by the Medicare recipient.

Modes of premium payment

References to the fashion and frequency in which premiums are paid are called a MODE. The premium payment modes are as follows: A. ANNUALLY- Premium payments are made once a year. This method of paying is the most economical (least expensive) for the insured. B. SEMI-ANNUAL- Premium payments are made every 6 months. C. QUARTERLY- Premium payments are made every three months. D. MONTHLY- Premium payments are made monthly. Most expensive mode. E. BANK DEDUCTION- Premium deducted from savings or checking account. F. PAYROLL DEDUCTION- Employer deducts premium from paycheck.

Types of Medicare Advantage Plans

1. Medicare Advantage Health Maintenance Organization (HMO) 2. Medicare Advantage Preferred Provider Organization (PPO) 3. Medicare Advantage Private Fee-For-Servie-Plan- (PFFS)

4 Parts to Medicare

1. Part A-Hospital Insurance (HI) 2. Part B- Supplemental Medical Insurance (SMI) 3. Part C- Combines Part A & B Through an HMO or PPO 4. Part D- Prescription Drug Benefit Medicare is federally funded and federally administered. Medicare is administered by the Centers for Medicare & Medicaid Services (CMS), a federal agency in the Department of Health and Human Services. cms.gov

2 Terms used when a death benefit is paid out:

1. Primary Beneficiary 2. Contingent Beneficiary

3 Areas of Social Security

1. Retirement 2. Disability 3. Death

State Health Insurance Assistance Program (SHIP)

A free counseling service for Medicare beneficiaries and their caregivers. the Medigap helpline is provided by the State of Wisconsin Board on Aging and Long Term Care at no charge for advice.

A dependent child is:

A. A child under the age of 19 (stepchildren and legally adopted children are included). B. If still in school full-time, coverage may continue up to age 25. C. Handicapped children may continue coverage regardless of age. Coverage is the same as other children when the child is born.

Retirement

An individual may start to receive benefits at age 62. Each year the individual waits to retire, monthly payments are larger, until full retirement age. If an individual's full retirement age is 67, the reduction in monthly payments for starting their Social Security at age 62, is 30%; at age 63, it is 25%; at age 64, it is 20%, at 65, it is 13 1/3%, and at age 66, it is about 6 2/3%. The reduction for early retirement is permanent, although monthly payments increase each January to reflect the changes in the cost of living. Individual may increase their monthly payments if they work past full retirement age. If you were born in 1943 or later, Social Security will add 8% per year. You may do this until age 70. By itself, Social Security replaces about 40% of an average wager earner's salary.

Reviewing your disability

An individual receives benefits as long as they are disabled. The individual does have to go through a review periodically to see if they are still disabled.

Medicare Benefits

An individual will automatically be enrolled in Medicare after you have been getting disability for two years.

Medicare Select Policies

Are offered by insurance companies and HMO's. They are basically the same as Medicare supplement insurance in nearly all respects. The only difference is that Medicare Select policies will only pay full supplemental benefits if covered services are obtained through specified health care professionals. Emergency care is covered if outside the HMO provider.

Medicare Advantage Preferred Provider Organization (PPO)

Basically the same type of plan as the HMO except that the individual has the option of going outside the network but they would have to pay an additional cost.

Part A Hospital Insurance

Covers: Semi-private room & board, general nursing care, special care units, diagnostic x-rays, operating and recovery room, rehabilitation services, miscellaneous hospital services and supplies, meals, drugs, lab test, medical supplies, anesthetics.

Benefit Period for Part A:

First 60 Days- Medicare recipient pays a deductible of ($992, 2007), and Medicare pays the rest. 61st-90th Day- Individual pays 1/4 of the current deductible ($248, 2007) each day with Medicare paying the balance. 91st-150th Day- Individual pays 1/2 of the current deductible ($496, 2007) each day with Medicare paying the balance. Beyond 150 Days- Medicare recipient will pay for all the hospital bill. Premium for Part A: It is free! You do not pay anything for it.

Currently Insured

Means that an individual has earned at least 6 quarters of coverage during the last 13 calendar quarters. It also means that the individual is eligible for some benefits, but not as much as if they were fully insured. There would be benefits available for Social Security Survival Benefits, including the Social Security Death Benefit.

Part D- Prescription Drug Plan- An OPTIONAL plan

Part D is an optional selection and the insured pays a monthly premium. This coverage may lower prescription drug cost and help protect against higher costs in the future. When you use Part D, you will pay a deductible, coinsurance, and co-payments for your prescription drugs.

Death Benefit

Social Security will pay a lump sum death benefit of $255 to a surviving spouse who is living with you at the time of death. The children may receive the benefit if the spouse has passed away. Qualified beneficiaries may receive this benefit if you are employed or retired at the time of death.

Primary Beneficiary

The person(s), charity, trust, or other entity that is named first in the life insurance policy and has the first priority in receiving death benefit proceeds.

Chiropractic Care

The usual and customary expense for services provided by a chiropractor. This benefit is available even if Medicare does not cover the claim.

Diabetes Treatment

The usual and customary expenses incurred for the installation and use of an insulin infusion pump or other equipment or supplies, including insulin, in the treatment of diabetes. Self-management services are also considered a covered expense. This benefit is available even if Medicare does not cover the claim.

Part C- Medicare Advantage Plan

This health plan option is directed through an HMO, PPO, or private Fee-For Service Plan. These plans are a combination of Medicare Part A & B and must cover medically- necessary services.

Breast Reconstruction

Will cover breast reconstruction of the affected tissue incident to a mastectomy.

Coverage of Certain Health Care Costs in Cancer Clinical Trials

Will cover certain services, items, or drugs administered in cancer clinical trials in certain situations. Medicare Advantage insurance plans are not required to cover Wisconsin's mandated benefits.

Medicare Advantage Health Maintenance Organization (HMO)

With the HMO Medicare Advantage policy, you are "locked in," meaning that, except for emergency or urgent care situations away from the home, you must receive all services, including Medicare services, from HMO contracted doctors or other providers. If you go outside the HMO, you must pay for all charges out of your own pocket, including Medicare costs.

Benefits for family members

Your wife or husband age 62 or older- One half of the retired worker's full benefit, unless spouses takes benefit before age 65, then the benefit is reduced. Your wife or husband under age 62, if she or he is taking care of your child who is under the age of 16 or is disabled. One-half of retired worker's full benefit, regardless of age. Your former wife or husband age 62 or older. Must have been married for 10 years or more, and former spouse may not get remarried. Children up to age 18, if they are full time elementary school students. Children over age 18, if they are disabled.

Waiting Period

Disability benefits begin after a waiting period OF FIVE FULL MONTHS. You must have been disabled continuously for the full five months to qualify for benefits. PAYMENTS BEGIN IN THE 6TH MONTH.

Not Covered under Part B:

Foreign Travel, Most immunizations, Health screenings, In-hospital private-duty nursing, nursing home, private nurses, CUSTODIAL CARE (WALKING,DRESSING, BATHING), Over-the-counter drugs, or drugs self-administered, dental care and dentures, routine physicals and eye exams, eyeglasses or hearing aids, telephone or TV in the hospital, most prescription drugs, routine foot care.

Fully Insured Status

Having the proper number of quarters required to receive the full benefit amount. You must be fully insured to receive retirement or disability benefits from Social Security.

Social Security Disability- 2Kinds

If an individual becomes disabled, they may receive benefits under two different programs. The two government programs are called: A. Social Security Disability- Prior work B. Supplemental Security Income Disability - financial need - The difference between the two programs are simple. Social Security Disability is based on prior work, while Supplemental Security Income is based on financial need. - The medical requirements for both programs are the same. The definition of disability is the inability to engage in SUBSTANTIAL GAINFUL ACTIVITY. An individual is considered to be disabled if they are unable to do any kind of work for which they are suited, and only if your inability to work is also EXPECTED TO LAST FOR AT LEAST A YEAR OR EXPECTED TO END IN DEATH.

Contingent Beneficiary

In case the primary beneficiary dies before the insured, the contingent beneficiary will receive the death benefit when the insured dies. If there are no remaining benefices, the death benefit will be paid to the insured's estate.

Social Security Disability

Individuals able to receive disability benefits are: 1. Any individual at any age who fits the description of disability. 2. If disabled, when you turn age 65 your monthly benefit turns into retirement benefits, but the amount remains the same. 3. An individual's unmarried son or daughter, including a step-child, adopted child, or in some cases a grandchild. The child must be 18 or under 19 if still in high school. 4. An individual's unmarried son or daughter, 18 or older, if he or she has a disability that started before age 22. 5. Your spouse who is 62 or older. 6. Your spouse at any age if he or she is caring for a child of yours who is under 16 or disabled and also receives checks. 7. Your disabled widow or widower 50 or older. The disability must have started before your death or within 7 years after your death. 8. Your disabled ex-wife or husband who is 50 or older if the marriage lasted 10 years or longer.

Disability benefits for people with HIV infection

Individuals with the HIV or AIDS may also qualify for disability benefits when they are no longer able to work or if they are limited in the work they may perform. Some individuals with the HIV virus may also qualify.

Wisconsin Medicare Basic Benefits

Inpatient Hospital Care: Covers the Medicare Part A coinsurance. Medical Costs: Covers the Medicare Part B coinsurance. Blood: Covers the first three pints of blood each year.

Kidney Disease

Inpatient or outpatient expense for dialysis, transplantation, or donor related services of kidney dies ease up to $30,000 in any calendar year.

Optional Riders to the Basic Plan Coverages

Insurance companies are allowed to offer these five riders to a Medicare supplement policy. 1) Medicare Part A Deductible 2) Additional Home Health Care (365 visits including those paid by Medicare) 3) Medicare Part B Deductible 4) Medicare Part B Excess Charges 5) Foreign Travel

Medicare Select Policy Coverages

Medicare Select policies will provide the same coverage's as the Basic Medigap policy, but will automatically cover the Part A Deductible, and Foreign Travel. You do not need to pay an additional premium for these benefits as you would in a Medigap policy.

Title 18- Medicare and Title 19- Medicaid

Medicare and Medicaid were passed into law in 1965. The programs started July 1, 1966. Medicare was intended to cover medical expenses to individuals over the age of 65. Medicaid is medical care for the low-income population.

Medicare

Medicare is a federal health insurance program for: A. People 65 or older B. People of any age with end-stage renal disease (ESRD) requiring dialysis or kidney transplant C. Disabled individuals who have received disability benefits for two years from Social Security and are under age 65.

Skilled Nursing Facilities

Medicare supplement and Medicare policies include 30 days of skilled nursing care in a skilled nursing facility. The facility does not need to be certified by Medicare and the stay does not have to meet Medicare's definition of skilled care. No prior hospitalization may be required.

Home Health Care

Medicare supplement and select policies must provide for all medically necessary home health visits. All Medicare supplements will pay up to 40 days. YOU MUST QUALIFY, meaning your physician has certified that you need to be in a hospital or skilled nursing facility because home health care was not available to you.

Social Insurance- Social Security Benefits

The Social Security Act was signed into law on August 14, 1935 under President Franklin D. Roosevelt. Called the Old Age Survivors Disability Insurance (OASDI), the law was intended to provide financial protection at retirement, protection for severe disability, or death. An individual and employer both share in paying a tax on employee wages for Social Security. Breakdown as follows: Employer pays 6.2% for Social Security, and 1.45% for Medicare Part A. Employee pays 6.2% for Social Security, and 1.45% for Medicare Part A. A self-employed individual may have to pay both halves of the tax, or 15.30% (8.10% in 1980). In 2007, any earnings over $97,500.00 (Maximum Taxable Amount) are not subject to the Social Security tax (6.2%), but there is no Maximum Taxable Amount for Medicare Part A Portion (1.45%), it continues to be taken out.

Monthly Benefit Amount

The amount of your monthly disability benefits is based on your lifetime average earnings covered by Social Security.

Work credits needed to qualify

The earning of work credits needed to qualify are determine the same way as they were for retirement benefits. THE MINIMUM IS 6 CREDITS/QUARTERS, THE MAXIMUM IS 40 QUARTERS. The exact number needed is determined by your age and years of work.

Primary Insurance Amount (PIA)

The monthly amount payable to a retired worker who begins to receive benefits at normal retirement age (62) or (generally) to a disabled worker. This amount, which is related to the worker's average monthly wage or average indexed monthly earnings, is also the amount used as a base for computing all types of benefits payable on the basis of one individual's earnings record.

Non-Duplication and coordination of benefits

To prevent a person from having more than one policy pay full benefits for one claim, the non-duplication principal was developed. This principal defines a policy's liability as limited to the same proportion that all other policies hold in the instance of a claim. Therefore, if a person had four health insurance policies, they would receive one-fourth of benefits from each contract, thus equaling benefits of one policy. Likewise, COORDINATION OF BENEFITS also prevents one from profiting from group or social provider policies. In a claim, the following insurances are deemed as to be PRIMARY benefit providers, with private coverage as SECONDARY providers: 1. Group Insurance 2. If both parents work, dependent children are covered under the parent whose birthday falls earlier in the year 3. Automobile medical payment coverage 4. Union welfare plans 5. Hospital or Medical service organization 6. Employee welfare benefit organization 7. Medicare Once the primary plan has paid out their specified benefits, the secondary plan may pay for benefits not covered under the primary plan (deductibles, coinsurance). But, the total amount of benefits received may not exceed the actual medical expense.