Chapter 8

Question 1

Medicare

Answer 1

A federal medical expense insurance program for people age 65 and over, employed or not. Also for anyone who has been entitled to Social Security disability income benefits for 2 years or has ESRD

Question 2

Medicare Part A (hospital)

Answer 2

Financed through a portion of payroll tax (FICA); Pays for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice

Question 3

Eligibility for Medicare Part A

Answer 3

Citizen or legal resident of U.S. age 65+ and qualified for SS or Railroad retirement benefits; 65+ and entitled to monthly SS benefits based upon spouse’s work record, and spouse is at least 62; younger than 65 but has been entitled to SS disability benefits for 24 months; has ALS or ESRD

Question 4

Enrollment Periods for Part A

Answer 4

Initial, general, and special

Question 5

Inpatient hospital care

Answer 5

Pays for 90 days in hospital, possible deductible. First 60 days are covered 100% after deductible is met. They next 30 are paid but subject to copayment.

Question 6

First 20 days in a skilled nursing facility

Answer 6

Are covered 100% by Part A, but Part A will help pay for 100 days

Question 7

Home Health Care

Answer 7

For an individual being confined to the home, hospital insurance can pay the full approved cost of home health visits

Question 8

Part A Exclusions

Answer 8

dental care/dentures; cosmetic surgery; custodial care, unless skilled nursing care is provided at the same time; health care outside of US; hearing aids and exams; most prescription drugs; routine eye care; immunizations; first 3 pints of blood

Question 9

Medicare Part B (Medical)

Answer 9

Financed from monthly premiums paid by insured’s and from general revenues of the federal government; pays for doctor’s services and other medical services/supplies not covered in Part A

Question 10

Part B Eligibility

Answer 10

Optional and offered to everyone who enrolls in Part A

Question 11

Part B Enrollment

Answer 11

You are offered Part B after becoming eligible for Part A. If you decline, you must wait until the next general enrollment (January 1-March 31) to enroll

Question 12

Home Health Visits

Answer 12

Will be paid for if recommended by doctor and insured is eligible

Question 13

Prescription Drugs

Answer 13

Only covers medicine administered in a hospital outpatient department such as injected drugs at doctor’s office, some oral cancer drugs, or drugs that require durable medical equipment

Question 14

Part B Exclusions

Answer 14

Private duty nursing, skilled nursing home care costs over 100 days per benefit period, charges above Medicare approved amount, most outpatient prescription drugs, care received outside of US, custodial care received in home, dental care (except accidental), eyeglasses, hearing aids

Question 15

Medicare Part C (Advantage)

Answer 15

Allows people to receive all of their health care services through available provider organizations; Must cover all services covered under Original Medicare (Part A and B) except hospice; provided by HMO’s or PPO’s

Question 16

Part C Eligibility

Answer 16

Must be enrolled in Part A and B

Question 17

Medicare Part D (Prescription Drugs)

Answer 17

Optional coverage provided through private prescription drug plans that contract with Medicare

Question 18

Part D Benefits

Answer 18

To be received, coverage must be offered by plan in the area and individual must be enrolled in Part A or Parts A and B

Question 19

Part D Enrollment

Answer 19

If one does not enroll when first eligible they must pay a 1% penalty for every month enrollment is delayed

Question 20

Integrated Plan

Answer 20

Groups coverages together, including HMOs and PPOs

Question 21

Stand-Alone Plans

Answer 21

Fee-for-service

Question 22

Donut hole

Answer 22

When benefit limit is reached, beneficiary is responsible for a portion of costs

Question 23

Catastrophic coverage

Answer 23

When spending reaches limit of coverage gap, 95% is prescription drug costs will be covered

Question 24

Medicare Supplements

Answer 24

Supplement plans known as Medigap are policies issued by private insurance companies to fill the gaps of Medicare; pays some or all of Medicare’s deductibles and copayments; sold and services by private insurers and HMOs

Question 25

Medicare Supplement/Medigap Enrollment

Answer 25

Person may not be denied based on health status, claims experience, receipt of health care or medical condition

Question 26

Medicare Supplement/Medigap Open Enrollment

Answer 26

6 month period that guarantees applicant's right to buy Medigap upon signing up for Part B of Medicare. Must have Part A and B

Question 27

Standard Medicare Supplement Benefit Plans

Answer 27

Developed by NAIC; Plans go from A-N

Question 28

Core Benefits of Plan A

Answer 28

Must be found in all plans; Part A coinsurance/copayment, hospital costs, hospice coinsurance/copayment, Part B coinsurance/copayment, first 3 pints of blood

Question 29

Medicare SELECT

Answer 29

Medicare supplement policy that contains restricted network provisions - provisions that condition the whole of partial payment of benefits on the use of network providers

Question 30

Medicare SELECT costs

Answer 30

Negotiate with a provider network of doctors, hospitals and specialists to charge lower rates for medical services so costs are kept down for the plan provider and members pay lower premium

Question 31

Twisting

Answer 31

High-pressure tactics and misleading advertising

Question 32

Medicare Supplement Policy Exclusions

Answer 32

Losses for preexisting conditions incurred more than 6 months from the effective date of coverage cannot be excluded

Question 33

OBRA requirements

Answer 33

Large group health plans (100 employees or more) provide primary coverage for disabled individuals under 65 who are not retired; employer health plan provides primary coverage for individuals with ESRD for 30 months; If an employee is insured on a group plan of less than 20 employees, Medicare is primary coverage. Vice versa for groups of 20 or more

Question 34

Medicaid

Answer 34

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

Question 35

Medicaid Eligibility

Answer 35

Low income/assets, blindness, disability, pregnancy, age (over 65), caring for children with welfare

Question 36

Medicaid Benefits

Answer 36

Physician's services, inpatient/outpatient hospital care, skilled nursing home services, lab and x-Ray services, home health care, family planning, prescription drugs, dental, eyeglasses, private duty nursing, check ups, and medical equipment/supplies

Question 37

Long-Term Care (LTC)

Answer 37

Individual or group policies or riders that provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or in a nursing home.

Question 38

LTC Coverage

Answer 38

Must be provided for 12 consecutive months in a setting other than an acute care unit of a hospital

Question 39

LTC Eligibility

Answer 39

Must be unable to perform some of the activities of daily living (ADL)

Question 40

Comprehensive Coverage

Answer 40

Covers all care and services, except for those specifically excluded in the following settings: the insured's home (skilled nursing care, occupational, physical, and rehab therapy), adult day health care centers, hospice, respite, assisted living facilities, Alzheimer's special care facilities, and nursing homes

Question 41

Levels of Care

Answer 41

Skilled nursing care, intermediate care, and custodial care are covered. Coverage for home health, adult day care, hospice, and respite may be provided

Question 42

Skilled Care

Answer 42

Daily nursing and rehabilitative care that can only be provided by medical personnel under the direction of a physician

Question 43

Intermediate Care

Answer 43

Occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis; ordered by a physician, fulfilled by skilled medical personnel

Question 44

Custodial Care

Answer 44

Care for meeting personal needs such as assistance with eating, dressing, or bathing and can be provided by nonmedical personnel in an institutional setting or the patient's home

Question 45

Adult Day Care

Answer 45

Care provided for functionally impaired adults on a less than 24 hour basis

Question 46

Residential Care

Answer 46

Provided while the insured resides in a retirement community

Question 47

Assisted Living

Answer 47

Offers help with nonmedical aspects of daily activities

Question 48

Respite Care

Answer 48

A provides relief to family caregiver

Question 49

Benefit periods

Answer 49

The longer the benefit period, the higher the premium

Question 50

LTC Exclusions

Answer 50

Preexisting conditions and diseases; mental/nervous disorders/diseases; alcohol/drug addiction

Question 51

LTC Partnership

Answer 51

Allows those who have used some of their private LTC benefits to apply for Medicaid coverage without having to meet the same means/testing requirements

Question 52

Shopper's Guide

Answer 52

Must be provided by NAIC and presented to the applicant at the time of application

Question 53

Outline of Coverage

Answer 53

Must include information about the insurance company, policy number, and important features of the policy: separate document that must be delivered prior to application/enrollment form

Question 54

LTC Preexisting Conditions

Answer 54

LTC will not cover the first 6 months of the contract unless it is replacing another LTC policy

Question 55

Unintentional Lapse

Answer 55

Policy may not lapse due to unpaid premium unless 30 days' notice is given and a reinstatement of coverage provision should be included in the policy

Question 56

Nonforfeiture Benefit

Answer 56

May be a rider; must be offered

Question 57

Violation Penalty

Answer 57

If the requirements relating to the regulations of LTC insurance are violated or the marketing of LTC, a civil penalty of up to 3 times then amount of commissions or $10,000 is issued, whichever is greater