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Phar 738 > Medicare > Flashcards

Medicare Flashcards

1
Q

what is SHIBA?

A

part of state health insurance assistance programs (SHIP)

centers for medicare and medicaid services

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2
Q

what is SHIBAs mission?

A

to educate and advocate for medicare beneficiaries about their rights and options to help make informed decisions

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3
Q

what does part A cover?

A

inpatient care
skilled nursing care
home health care
hospice care

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4
Q

what does part B cover?

A 
doctors services & outpatient surgeries
preventative services
diagnostic tests
some drug therapies administered by dr
medical equipment
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5
Q

T/F you must have been a US citizen or legal resident in US for 5 years to be eligible for Medicare

A

True

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6
Q

T/F you can be automatically enrolled in medicare if you’re receiving social security benefits

A

True

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7
Q

can you enroll into part A without enrolling into part B?

A

Yes

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8
Q

when is the initial enrollment period? when does enrollment begin?

A

3 months before the month you turn 65.
begins first day of the month you turn 65
or
you can apply during the month of your birthday and receive benefits the month after birthday
or
up to 3 months after turning 65, enrollment will be delayed 2-3 months

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9
Q

when is the general enrollment period? when does it take effect?

A

january-march of each year.

starts july of the year you enroll

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10
Q

if you enroll into medicare over 3 months after your birthday and you are not in the months january-march, how long until you can get medicare benefits?

A

must wait to apply in january to become enrolled in july

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11
Q

can you wait to enroll into part B and D if you have other employer coverage at 65?

A

Yes

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12
Q

why is it recommended to enroll into part A even if you have employer ins?

A

theres no premium

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13
Q

if fewer than 20 employees at your job, why should you get part B?

A

medicare acts as primary payer and employer ins acts as a secondary

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14
Q

what is the special enrollment period (SEP)? (part B)

A

if you’re getting part B late due to employment you qualify for SEP which allows you to enroll for up to 8 months from loss of ins

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15
Q

what is the penalty for not enrolling into part B when suggested?

A

current premium rate + 10% for each year delayed, payed for LIFE

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16
Q

does COBRA ins count as part B or D exemption?

A

no

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17
Q

if you are on medicaid can you stay on it turning 65 instead of going onto medicare?

A

no, you must apply for medicare and then you can additionally reapply for medicaid

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18
Q

can VA insurance replace part B?

A

no

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19
Q

how do you qualify for premium-free part A?

A

10 years of work history or 40 quarters

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20
Q

does your spouse qualify for premium-free part A as well?

A

yes if married over 5 years

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21
Q

two ways for low-income people to pay for part B premium?

A

with social security pension

qualify for medicaid state may pay

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22
Q

Which shots does part B cover?

A

flu
pneumococcal
hep B

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23
Q

how can you pay for things not covered by medicare?

A

private insurance - supplement insurance (medigap)
medicare advantage plans
tricare/VA
medicaid

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24
Q

what is a medigap plan?

A

provided by private companies
pays what medicare doesnt cover
plans A-N
no drug coverage

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25
Q

what is the initial enrollment period for medigap?

A

up to 6 months after enrolling in medicare part B

26
Q

qualifications for special enrollment for medigap:

A

disabled, turning 65
loss of coverage out of your control
first 12 months in a medicare advantage plan at 65

27
Q

T/F you cannot be denied when applying outside of the guaranteed issue period due to pre-existing medical issues (underwriting)

A

False, you CAN be denied

28
Q

what is Oregon’s “birthday rule” for people who already have medigap?

A

beginning on someones birthday and for 30 days after they can change plans without underwriting

29
Q

what is medicare part C?

A

private advantage plan, acts as primary payer for medical services and usually includes prescription drug coverage

30
Q

PPO vs HMO Medicare

A

PPO: any provider that accepts medicare
HMO: usually need a referral to see a specialist, must choose a PCP in network

31
Q

when is initial enrollment period for advantage & drug plans?

A

same as part B or 60 days after employer plan ends

32
Q

when is Annual election period for advantage & drug plans?

A

oct 15- dec 7

33
Q

qualifications for Special enrollment periods for advantage plans:

A

move out of plan’s service area
plan leaves your service area
if you qualify for extra help
if employer coverage ends or you quit working

34
Q

Medigap plan vs Advtantage plan: premiums

A

medigap has higher premiums

35
Q

Medigap plan vs Advtantage plan: drug coverage

A

medigap: none (except PERS)
advant: yes

36
Q

what are some other coverage options for plans that have medicare-specific options?

A

PERS, Union, Federal Retirees

37
Q

if you have VA ins or tricare for life, what other supplementation are you still required to obtain for medicare?

A

part B

38
Q

what are the two types of drug coverage options? (medicare)

A
  • original medicare

- medicare advantage prescription drug plans

39
Q

what is the part D waiting to enroll penalty?

A

1% premium increase for every full month
delayed– beginning 3 months after turning 65 or
6 months after leaving employer plan

40
Q

list the co-payment “tiers” and their general meaning

A 
tier 1: low cost generics
tier 2: high cost generics
tier 3: comon "preferred" brand drugs
tier 4: higher cost brand drugs
tier 5: specialty drugs
41
Q

can you have a monthly premium for part D?

A

yes

42
Q

can you have a annual deductible for plan D?

A

yes

43
Q

how much is your typical co-pay after the initial benefit period after deductible for part D?

A

25%

44
Q

what is the part D “coverage gap” or “donut hole”?

A

after client and ins have paid a fixed amount, then client pays 25% for all drugs

45
Q

what is part D “catastrophic coverage”

A

after client has paid a fixed amount max co-pay is 5% or fixed low cost

46
Q

when is initial enrollment period for part D?

A

7 month period around 65th birthday (same rules as part B)

47
Q

when is the fall annual enrollment period for part D?

A

oct 15 - dec 7

48
Q

when is special enrollment period for part D?

A

60 days after retirement or moving

jan 1 - feb 14 if disenroll from an advantage plan

49
Q

does max out of pocket for medical costs apply to part D portion of advantage plan?

A

no

50
Q

when can a low-performing drug plan be terminated?

A

if plan receives a score of less than 3 stars for 3 consecutive years

51
Q

what is limited income subsidy? (LIS)

A

federal program by social security for prescription drug assistance
-typically pays entire part D premium

52
Q

what is medicare savings plans (MSP)

do people using MSP qualify for LIS?

A

medicaid plans
pays part B premiums
-yes

53
Q

T/F people on LIS have continuous open enrollment priviledges

A

true

54
Q

what is the full dual medicare savings program?

A

similar to OHP: includes medical costs and dental benefits

55
Q

what is the qualified medicare beneficiaries (QMB)?

A

covers part B premiums, , deductibles and co-pays (cost sharing) paid by the state. no dental

56
Q

SMB/SMF and QI: what does it pay for?

A

part B premium and drugs, not medical

57
Q

what did the affordable care act change for medicare?

A
  • inc access to preventative care
  • inc # of beneficiaries paying higher part B premiums
  • close part D coverage gap (donut hole)
  • others, refer to week 3 slide 4
58
Q

biparitsan budget act of 2018: what happened in 2020?

A

part D enrolless pay 25% now

59
Q 
Summarize Part A:
Primary use
Premium
Deductible (60-day benefit period)
When do you pay co-pays
A

Hospital insurance
Free for most
~$1450 for each 60-day benefit period
Co-pays after 60 days

60
Q 
Summarize Part B:
Primary use
Premium
Deductible (per year)
Co-insurance
A

Outpatient medical insurance
~$150/month
~$200 per year
20%

61
Q 
Summarize Supplement/Medigap Plans
What are the choices?
Which plan is most comprehensive?
Which plans were discontinued in 2020?
Does it include drug coverage?
Most people need to buy what Medicare plan with it?
High/low premium?
Is there a co-pay?
Nationwide coverage?
A 
Plans A-N
Plan G
Plans C and F
No
Part D
High premium
No co-pays
Yes
62
Q 
Summarize Medicare Advantage Plans
What are the choices?
Does it include drug coverage?
High/low premium?
Is there a co-pay?
Nationwide coverage?
A 
PPO or HMO plans
Yes
Low premium
Yes
No, best for in-network providors

Phar 738 (8 decks)

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