Government Health Insurance Plans
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
MPB exclusions does not cover
- 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 the home - Dental care, cosmetic surgery, eyeglasses, hearing aids, orthopedic shoes, acupuncture expenses - Expenses incurred due to a war or act of war
Government Insurer
- Provides coverage for some disabled individuals and those over age 65 in the form of medicare and Medicaid - Offers disability insurance protection through the social security system
Private insurance
- Provides the large portion of all individual and group health insurance
Coinsurance
- The portion of medicare's approved amount that the beneficiary is responsible for paying
Pap smear screening
- To screen for cervical cancer once every 2 years
MPD standard prescription drug benefit
- Will monthly premium and a deductible varies by plan. - Provide prescription drug benefits until a benefit limit is reached - Donut hole occurs when limit is reached - The beneficiary is responsible for the portion of drug cost
Qualifications for disability benefits for SSD
- Worker must be fully insured or currently insured - Worked for 40 quarters - Have had at least 16 calendar quarters of coverage - At least 6 quarters of coverage out of the last 13 quarters period
MPB Enrollment
- You can enroll when you're eligible for Part A - If decline and reinstated, must wait until next enrollment period
Medicare HMOs
- Managed care plans - Doctors and hospitals that join the plan network - Insured may be asked to choose a primary care physician - Doctors can join or leave managed care plan any time
Durable Medical Equipment
- Medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home
MPB Coverage and Cost Sharing Amounts
- Medical insurance will generally pay for 80% of the approved charges for covered expenses for the remainder of the year. - Out of pocket limit on the 20% coinsurance
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
Medicaid
- Offers assistance as both federal and state sponsored program
Social Security Disability Income Benefits
- Old Age Survivor Disability Insurance - Federal program enacted to designed to provide protection for eligible workers and their dependents against financials loss due to old age disability or death - Plays a role of federal life and health insurance
MPB prescription Drugs
- Only medicines that are administered in a hospital outpatient department under certain circumstances, such as injected drugs at a doctor's officer, some oral cancer drugs, or drugs that require are covered - Insured may have to pay 100% if not covered by Part D
Medicare Part D - prescription Drug Insurance
- Optional coverage provided through private prescription drug plans - Beneficiaries must sign up with a plan offering this coverage in their area and must enroll in part A or both Part A n B
Carrier
- Organizations that process claims that are submitted by doctors and suppliers under medicare
Comprehensive outpatient rehabilitation facility services
- Outpatient services received from a medicare participating comprehensive outpatient rehabilitation facility
Medicare is divided into 4 parts
- Part A, hospital insurance, is financed through a 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 government - Part C, allows people to receive all of their health care services through available provider organizations - Part D, is for prescription drug coverage
Medicare Part B
- Pays for doctor's services and a variety of other medical services and supplies that are not covered by hospital insurance - Usually people with permanent kidney failure
MPB home health visit
- Pays for home health services as long as these services are recommended by the insured's doctors and the insured is eligible. - If not fully cover by medicare, it will get coverage from Medicaid
Medicaid Title 19 state must provide to receive Benefits
- Physician's service - Inpatient hospital care - Outpatient hospital care - Skilled nursing home - Lab and x ray service - Home health care services - Rural health clinic services - Periodic screening diagnosis and treatment - Family planning services - Medicaid pays for prescription drugs, dental service, private duty nursing, eyeglasses, check up, and medical supplies and equipment
MPB yearly "wellness" visit
- Preventive visit available during the first 12 months - No out of pocket cost for the insured - May pay coinsurance if further test are done - Maybe deductible
MPC Special Need plan
- Provides more focus and specialized health care for specific groups of people - People who have both Medicare and Medicaid
Medicare is administered by
- The Center for Medicare and Medicaid Service
Approved amount
- The amount Medicare determines to be reasonable for a service that is covered under part B of Medicare
Actual Charge
- The amount a physician or supplier actually bills for a particular service or supply
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
Assignment
- The physician or a medical supplier agrees to accept the medicare approved amount as full payment for the covered services
Partial hospitalization for mental health treatment
- A program of outpatient mental health care
Disability Income Benefits for SSD
- Based upon the worker's primary Insurance amount, calculated from their average indexed monthly earnings over their highest 35 years, - The lowest 5 years of income may be deleted from calculation
Definition of disability for SSD
- Being fully insured or partially insured - As the inability to engage in any substantially gainful activity by reason of a medically determinable physical or mental impairment that has lasted or is expected to last 12 months or result in an early death
MPA Hospice Care
- Can pay for terminally ill insureds - Covered services, doctors, nurse, drugs, counseling
MPA home health care
- Can pay the full approved cost of home health visit - No limit to the number of covered vists - Covers part time skill nurse, therapist, services
If not eligible for Medicare Part A
- Can purchase the coverage for a monthly premium - If failed to sign up, pays 10% increase premium
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 in-patient hospital surgery
Medicare Part A eligibility requirement
- Citizen or 65+ yo qualified for Social Security or Railroad retirement benefit - 65+ entitled to monthly social security benefit based upon the spouse's work record and the spouse is at least 62 - Is younger than 65, but has been entitled to social security disability benefits for 24 months, disabled - Has end stage renal disease, permanent kidney failure that requires dialysis or transplant, ESRD - Has ALS, amyotrophic lateral sclerosis or lou Gehrig disease, automatically qualifies for the month disability benefits begin
MPB doctor services
- Covers doctors services no matter where received in the US.
Medicare Part C - Medicare advantage
- Medicare + Choice to Medicare Advantage
MPC Eligible
- Must enroll in Medicare Part A and B
MPC Medicare Private Fee for service plan
- Offered by private insurance company - Set money every month so private insurance company can provide health care coverage - Insurance company decides how much enrollees pay for the service they get
MPB other medical and health services
- Covers other medical services and supplies - Ambulance transportation, home dialysis equipment, supplies, periodic support services, independent lab test, oral surgery, outpatient physical therapy, speech pathology services, x ray and radiation treatments
MPB Outpatient Hospital Services
- Covers outpatient hospital services received for diagnosis and treatment such as care in an emergency room, outpatient clinic or a hospital
MPB outpatient Treatment of mental illness
- Covers outpatient treatment of an approved condition - Enrollee pays 20% of the medicare approved amount - Inpatient mental health care is covered under part A
Participating doctor or suppliers
- Doctors and suppliers who sign agreements to become Medicare-participating, 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
Medicare Title 18
- Federal medical expense insurance program for people age 65 and up. - Benefits are available to anyone, regardless of age, who has been entitled to social security disability income benefit for 2 years
Pee review organizations
- Groups of practicing doctors and other health care professional who are paid by the government to review the care given to medicare patients
MPC provided by
- HMO and PPO - Do not charge premium - No claims forms required - Requires medical services through the plan
Medicare Part A
- Helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care
MPA skilled nursing facility care
- Helps pay up to 100 days - Insured doctor must certify that daily skilled care is necessary - Covers semi private room and nurse
MPA inpatient hospital care
- Helps pay up to 90 days in a participating hospital in any benefit period - First 60 days are covered 100% once deductible are met - Next 30 days are copayment - Covers room, meal, tests, blood. - Does not include private room and nurse
MPD enrollment
- If don't enroll when first eligible, they must pay 1% each month they delay enrollment - May choose stand alone plan that offers coverage on a fee for service basis - Or pick integrated plans that group coverages together, including PPO HMO
MPD catastrophic coverage
- If the beneficiary spending during the gap reaches the limit - Will cover 95% of prescription drug cost - Cost for generic drugs would be lower than brand ones
Medicaid Title 19 Eligibility
- Individual must meet income and other eligibility requirement - Qualify with low income and low asset, - Qualifier of blindness, disability, pregnancy, age over 65, caring for children receiving welfare benefits - Individual need to satisfy federal and state requirement regarding residency, immigration status and documentation of us citizenship
Medicare Part A, Enrollment options
- Initial enrollment period - 3 months before turning 65, becomes eligible for Medicare - General Enrollment period - January 1st and March 31st each year - Special enrollment period - at any time during the year if the individual or their spouse is still employed and covered under a group health plan
Waiting period for SSD
- Is 5 months - Benefits begin at the beginning of the 6th month and are not retroactive to the beginning of the disability
What is Medicaid
- Is a federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care
MPB individual eligibility requirement
- Is optional and offered to everyone who enrolls in Part A. - Its funded by monthly premiums and from the general revenues of the federal gov't
