Chapter 8: Medicare & Long-Term Care Insurance

Cost-Sharing

Sharing of expenses between the insured and the insurance company through deductibles, copays, and coinsurance

For an individual who is eligible for Medicare at age 65, and who is still employed and covered under the employer's plan, which of the following is true?

The employer plan is primary coverage, and Medicare is secondary coverage.

What happens when an individual fail to sign up for Part A when they are first eligible?

The monthly premium may go up 10% unless the person becomes eligible for a special enrollment period

Outline of Coverage

a document required with all health insurance policies that provides a full coverage disclosure to the applicant

Benefit Period

a period of time during which benefits are paid under the policy

Enrollee

a person enrolled in a health insurance plan, an insured (doesn't include dependents of the insured)

What is Medicare Part A?

Hospital Insurance and is financed through a portion of the payroll tax (FICA) (Examples: Helps pays for inpatient hospital care, inpatient care in a SNF, home healthcare, & hospice care)

Inpatient Hospital Care

Hospital insurance helps pay for up to 90 days in a participating hospital in any benefit period, subject to a deductible *First 60 days are covered at 100% of approved charges after the deductible is met etc

Attained Age

the insured's age at the time the policy is issued or renewed

Skilled Nursing Facility

Part A helps pay for up to 100 days in a participating SNF in each benefit period following a 3-day inpatient hospital stay for a related illness

Open Enrollment

6 month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare Part B

How many years must a person be entitled to Social Security benefits to qualify for Medicare?

2 years

Following hospitilization because of an accident, Bill was confined in a SNF. Medicare will pay benefits for how many days?

20-days Following hospitilization for at least 3 days, if medically necessary, Medicare pays for all covered services during the first 20 days in a SNF.

Nonforfeiture Benefit

A cash or insurance benefit received by a policyholder who no longer wishes to make payments after making premium payments for at least the minimum period.

Medicaid

A federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care

Medicare

A federal medical expense insurance program for people age 65 and older even if the individual continues to work

HMO (Health Maintenance Organization)

A prepaid medical service plan in which specified medical service providers contract with the HMO and which focus on preventative care.

Network Provider

A provider who enters into contractual arrangement w/other providers to provide medical services to the network subscribers

What is Medicare Part B?

Medical Insurance and is financed from monthly premiums paid by insured and from the general revenues of the federal government (Examples: Helps pays for doctor's services such as surgical services, physical therapy, diagnostic tests etc anywhere in the US )

What is Medicare Part C?

Medicare Advantage and it allows people to receive all of their health care services through available provider orgs

What happens when an individual qualifies for Social Security benefits at age 65?

Medicare Part A is automatically provided

Which part of Medicare covers Outpatient Hospital Services

Medicare Part B

Special Enrollment Period (SEP)

At any time during the year if the individual or his/her spouse is still employed and covered under a group health plan

General Enrollment Period (GEP)

Between Jan 1st and March 31st each year

What is the difference between the Medicare approved amount for a service or supply and the actual charge?

Excess Charge

3 Types of Enrollment Periods for Medicare Part A

Initial Enrollment Period (IEP) General Enrollment Period (GEP) Special Enrollment Period (SEP)

What is Medicare Part D?

Prescription Drugs (PDP)

Initial Enrollment period (IEP)

When an individual first becomes eligible for Medicare (Starting 3 months before turning age 65th birthday)