Senior Care Flashcards
(90 cards)
1
Q
What are the three policies that would make Medicare primary
A
- Individual policy (Medicare is primary)
- Medicare supplement
- Medicare carve-out plan (in a small group)
2
Q
When is Medicare secondary
A
- Employer has at least 20 employees and the employee is enrolled in active group coverage (he doesn’t want Medicare)
- Employer has at least 100 employees and the employee is under 65 and qualifies for Medicare due to a disability
- When an employee qualifies for Medicare due to permanent kidney failure (Medicare is secondary for the first 30 months and then will become primary)
3
Q
What is Medicare Part A for
A
In-patient hospitalization
4
Q
What covers the cost of Part A
A
It is through the Social Security tax during a person’s working years
5
Q
When is enrollment automatic in Part A
A
Age 65 and you have been receiving SS or Railroad Retirement benefits before 65 or you have been receiving SS or RR disability benefits for 24 months
6
Q
When is the initial enrollment period (IEP)
A
It is a seven month period starting three months before your 65 birthday and three months after your 65 birthday
7
Q
When is the annual general enrollment period (AEP)
A
First three months of the year (January - March)
8
Q
Define the special enrollment period (SEP) for Part A and B
A
If you are 65 years old and your group coverage is terminated, then you have an 8 month period that begins in the month after your employment ends or the group plan ends to enroll
9
Q
What does Medicare Part A cover (4)
A
- Semiprivate room
- Regular nursing
- Intensive care
- Drugs and labs administered in the hospital
10
Q
What are 4 things that Part A does not cover
A
- Private room (unless medically necessary)
- Private nursing
- Physician
- Surgeon
11
Q
How many days is a person eligible for coverage in each benefit period
A
Up to 90 days
12
Q
When is the benefit period (Part A)
A
Begins with admittance to the hospital and ends when the patient is out of the hospital for 60 days
13
Q
What if the patient re-enters the hospital within 60 days
A
Then there is no additional deductible
14
Q
Is there a deductible for Part A
A
Yes, there is a deductible at the start
15
Q
When does coinsurance kick in for Part A
A
61-90 days in the hospital
16
Q
What if a person is hospitalized for more than 90 days
A
Then they can use their reserve days
17
Q
How many reserve days does each person have
A
60 days
18
Q
Does coinsurance apply to reserve days
A
Yes
19
Q
How many days will Part A cover for psychiatric hospital care
A
190 days
20
Q
How does Medicare pay hospitals
A
Prospective payment system
21
Q
How does the Prospective payment system work
A
A patient is diagnosed with a diagnosis related group (DRG) and then the hospital is paid based on that DRG, regardless of the actual length of stay or cost of treatment
22
Q
What part is skilled nursing covered under
A
Part A
23
Q
What are 4 things that are required at SNFs
A
- Provide care under the supervision of a doctor
- Have a doctor available for emergency
- Provide 24 hour nursing
- Have at least one full-time RN
24
Q
In order to have Part A cover SNFs, what must happen
A
The patient has to be admitted to a SNF within 30 days after at least staying in the hosptial for 3 days
25
How many days will Part A cover in a SNF
100 days during a benefit period
26
Is there a deductible for a SNF under Part A
No
27
When does coinsurance kick in for a SNF under Part A
For days 21-100
28
Besides hospital and SNF, what are 3 other services that are covered under Part A
- Home Health Care
- Hospice Care
- Respite Care
29
What is covered under Home Health Care for Part A
- Unlimited number of days (including speech and PT)
- Part time care
- Cannot be more than 6 days per week
- Cannot last for more than 3 consecutive weeks
- No limit on the total number of visits
- No limit on the total number of weeks
- No deductible
- No coinsurance
30
If a patient does not have Part A, will home health still be covered?
Yes, it will be covered under Part B (if they have it)
31
Does Medicare home health care cover custodial
No
32
When is hospice used
If you have 6 months or less to live
33
What is covered under hospice for Part A
- No deductible
- No coinsurance
- Includes doctor, nursing care, pain relief, homemaker services and respite care
34
Define respite care
Provide care in a hospice up to five consecutive days in order to provide relief to a person caring for the terminally ill patient
35
In short, what does Part B cover
Non-hospital coverage (supplementary medical insurance)
36
Is there a premium for Part B
Yes, it is voluntary, so there is a premium
37
Can you re-enroll in Part B
yes
38
Is Part B automatically provided with Part A
Yes, it is automatically provided with Part A and you have to decline it if you don't want it
39
When can enrollment into Part B be delayed
When employer coverage is primary
40
What are 5 things that Part B covers
- Physician and surgeon services
- Outpatient and emergency room services
- Home Health, if not covered by Part A
- Ambulance
- Braces, artificial limbs, pacemakers
41
What are 6 things that Part B does not cover
- Custodial care
- Eyeglasses and hearing aids
- Cosmetic surgery
- Dental care
- Checkups
- Drugs that can be self-administered
42
What are three costs, besides premiums that a beneficiary must pay under Part B
- Deductible
- Coinsurance
- First 3 pints of blood
43
How much will Part B pay
80% of their "allowable charges" based on the Medicare Approved Amount
44
Is Medicare based on usual and customary charges
No, it is based on the Medicare Approved Amount
45
What does Medicare Part C cover
It covers the gaps between Part A and Part B
46
What types of things does Part C cover
- Long-term nursing
- Custodial
- Denture/dental care
- Eyeglasses
- Hearing aids
- Drugs
47
When can a person enroll in Part C
- When they become eligible
| - During open enrollment from October 15 - December 7th
48
If a private company wants to offer Part D plans, what do those plans have to be
They have to be at least as good as Medicare's standard benefit design plan
49
What does a member pay under Part D
- Premium
- Deductible
- Co-pay
50
When can a person enroll in Part D
- When they become eligible
| - During open enrollment from October 15 - December 7th
51
Define creditable drug coverage
When expected average drug payments paid by the plan are the same or higher than the standard Medicare drug coverage
52
What is the penalty if you do not enroll in Part D when your first eligible, and instead enroll at a later date (for Medicare eligible members who have non-creditable coverage)
They have an annual premium penalty of 1% for each month of delayed enrollment
53
What does a person pay if they see a non-participating provider for Medicare
They pay the entire charge, then get reimbursed from Medicare on the portion that they would have covered had they been participating, and then pays the rest OOP (balance billing)
54
What can non-participating providers charge Medicare patients
Up to 115% of the charge
55
Define Medicare Summary Notice (MSN)
Itemized summary of services provided from the preceding quarter
56
Define intermediaries
Insurance companies that have a contract with CMS and handle claims from hosptials, SNFs, Home health and hospice for Part A
57
Define carriers
Insurance companies that have a contract with CMS and handle claims from doctors and other providers of Part B and Part D services
58
If a new enrollee in Part B joins and wants to enroll in Part D, can they enroll during a Special Enrollment Period (SEP)
Yes, they can enroll in Part D during April - June
59
What gaps in coverage do Medicare Supplement policies (Medigap) cover
- Deductibles
- Coinsurance
- Charges above the Medicare limits
- Cost of additional uncovered services
60
When is the open enrollment period for Medicare Supplement polcies (Medigap)
Six month period after an applicant turns 65 and is enrolled in part B or becomes enrolled in Part B without regard to age
61
What does OBRA stand for
Omnibus Budget Reconciliation Act
62
What does OBRA require from insurers
It requires insurers to provide a six-month open enrollment period of which they cannot deny coverage due to a medical condition
63
Under OBRA, can pre-existing conditions be excluded
Yes temporarily
64
How many Medigap plans are insurance companies limited to sell
They can only offer 14 plans and they all must include core benefits
65
What Medigap Plan are all insurance companies required to sell
All have to have Plan A (core package) plus either Plan C or Plan F
66
To be eligible for Medigap, what must a person be enrolled in
They have to be enrolled in both Part A and Part B
67
Define a pre-existing condition exclusion under a Medigap policy
The exclusion can only relate to a medical treatment that the insured received within 6 months before their enrollment and may only exclude coverage for that condition no more than 6 months after the effective date
68
Is there a requirement to issue Medigap policies to persons under 65
No
69
What are the letters of the Medigap policies offered
Plans A - N
70
Is there a difference between the plans offered from different insurance carriers
No, for example, all Plans A will provide the same exact benefits regardless of who is selling them
71
What is the difference between the Medigap Plans offered from different insurance carriers
Premiums, coverage is the same
72
List the 5 core benefits that all insurance carriers must offer in Plan A
- Medicare Part A coinsurance
- Additional 365 days of hospital coverage paid at 100%
- Medicare Part B coinsurance
- Cost of 3 pints of blood
- Part A hospice coinsurance
73
What plans are considered catastrophic plans
M and N
74
What plans are no longer sold (but members can still keep them if they had them)
E, H, I and J
75
What does long-term care help with
It provides custodial care by assisting in activities of daily living (ADLs)
76
What does long-term care do
It helps fill in the gaps in coverage for long-term nursing care between Medicare and Medicare supplement policies
77
How does the waiting period (elimination period) work for LTC insurance
You have to pay for a certain number of days before LTC insurance kicks in to begin to pay
78
What type of days does LTC insurance use to count
They use service days and not calendar days
79
Define service days
Days in which the insured actually receives care
80
How does the calendar day waiting period work
It begins on the first day of LTC service and counts consecutive calendar days until the waiting period is satisfied
81
In order for LTC insurance to apply, how many ADLs will a person need help with
At least 3
82
Voluntary coverage is offered to active employees and who else?
Their spouses under a limited form of "guaranteed issue"
83
How is employer-sponsored LTC insurance generally underwritten
It is usually individually underwritten
84
When is Medigap guaranteed to be issued
- Applicant is 65
- Enrolls in both A & B
- Applies for a Medigap policy within 6 months after enrolling in traditional Medicare
85
Who can buy Long-term care policies
Anyone who is not eligible for Medicaid (they can not offer LTC to Medicaid eligible members)
86
Does Medicare provide any LTC benefits
No, you have to buy LTC benefits
87
Is SNF long-term care benefits
No
88
Define assignment of benefits
Physician agrees to accept the Medicare-approved amount
89
What is Medicare Advantage
Part C
90
What is Medicare Supplement
Medigap
