Medicare in General
A Utilization and Review Committee (URC) reviews what part of care?
All aspects of care
When does your benefit period start?
What is the coinsurance the beneficiaries are responsible for?
20%
What type of Insurers provide Medicare Advantage plans?
Private Health Care Firms
Is Part D Optional?
Yes
When must the Outline of Coverage be given?
At the time of application
Who funds Medicaid?
The Federal Government and State
What is an Elimination Period?
Period of time the insured is responsible for paying their own LTC until the policy benefits begin
Who does Medicare contract with to handle claims processing?
Medicare Administrative Contractors (MACs)
What is a Medicare Summary Notice?
An easy-to-read statement that lists health insurance claims information. It is not a bill
The amount of the Part B annual deductible may be adjusted every 2 years. (T/F)
False, it can be adjusted every year
When can beneficiaries make changes to their Medicare Advantage plans?
During Open Enrollment Period
What type of Insurers provide Part D plans?
Private Insurers
Can someone have a Medicare Supplement Policy and a Medicare Advantage Plan?
No, it is one or the other
Who determines Medicaid Eligibility?
Departments of Social Services (DSS) and the Social Security Administration (SSA)
What is the length of benefit?
Range from 1 year through a person's lifetime. Generally sold as 3 or 5 year periods.
How is Part A Financed?
Funded largely by the Hospital Insurance portion of the FICA payroll tax collected from workers and employers.
What types of Personal care will Medicare not cover in regards to Home Health Care? (Name 2)
Bathing, Eating, Dressing, Toileting, Transferring, Continence
Under Part B, what is Other Diagnostic Test classified as?
Medicare covers tests used to diagnose illness and injuries
What are the main differences between an HMO and a PPO?
With an HMO, you have to utilize a primary care physician and stay in-network, while with the PPO you do not.
Stand-alone plans are prescription drug plans (PDPs) for beneficiaries who have Original Medicare Part A and/or Part B.
What is the renewability for a Medigap Policies? and what does it mean?
Guaranteed Renewable, The issuer may not cancel or nonrenew a Medicare Supplement policy or certificate for any reason other than nonpayment of premium or material misrepresentation.
According to QMB, they will pay for?
Medicare monthly premium and Medicare deductibles and coinsurance
What is the two Renewability options?
Must be Guaranteed Renewable or Noncancellable
How can someone qualify for a Qualified Medicare Beneficiary (QMB)?
The person's monthly income has to be no more than the Federal Poverty Level plus a grace of $20.
What are considered the covered expenses? (Name 2)
- Semi-Private Room
- Meals
- General Nursing
- Miscellaneous Hospital services and supplies
With participating providers, who files the claims?
The doctor or provider
During the Open Enrollment Period (October 15th - December 7th)
Individuals who qualify for both Medicare and Medicaid automatically qualify for ________.
Extra Help
In order to purchase a Medicare Supplement Policies, I have to have what?
Medicare Parts A & B
A Medicaid applicant's assets may not be more than __________ for an individual or ___________ for a couple.
$2,000 / $3,000
What is the definition of Long-Term Care?
Designed to provide coverage for no less than 12 months.
May cover diagnostic, preventative, therapeutic, rehab, maintenance, or personal care as long as not in acute care unit of hospital (ICU)
What is the purpose of Medicare Prospective Payment System?
In order to change hospital behavior and to encourage more cost-efficient delivery of medical care, hospitals are paid a pre-determined rate for each Medicare admission.
In order to restart your benefit period for Inpatient Hospital Care, how many days consecutively does the beneficiary need to be out of the hospital?
60 Days
What are the 2 main covered services?
Doctor Care & Outpatient Medical Services and Supplies
What are one of the three characteristics that go with your PPO Plan?
- Prescription drug coverage usually is included
- Beneficiary doesn’t have choose a primary care physician
- Referral is not required to see a specialist in most cases
What are the three types of Prescription Plan Options?
- Stand-Alone Plan
- Medicare Advantage Prescription Plan
- Employer-Sponsored Retiree Plans
How long does Open Enrollment last for a Medigap policy?
6 months and begins on the first day of the first month that a person is at least 65 years old and is enrolled for benefits under Medicare Part B.
According to SLMB, what do they pay for?
Only pays for participants' Medicare Part B premium
Name 3 exclusions for a Long-Term Care Policy
- Nervous/Mental Disorders that are non-organic (Alzheimer's is covered)
- Alcohol/Drug Addiction
- Injury/Sickness caused by war
- Felony
- Military
- Self-inflicted
- Airplane related
What is the purpose of OEP?
The beneficiary can make changes to their Medicare Advantage plans, get a Medicare Advantage plan, make changes to their Part D coverage, Get a Part D plan
Other than Hospital Insurance, what are the three other types of coverage that Part A provides?
- Skilled Nursing
- Home Health Care
- Hospice Care
What type of prescription drugs can be excluded?
Ones that are self-administered
Special Needs Plans (SNPs) provide specialized care for specific groups. What are these groups?
- Those eligible for both Medicare and Medicaid
- Live in a nursing Home
- Suffer from certain chronic medical conditions such as ESRD
Minimum Standards: What is Annual Deductible?
The amount an individual must pay each year for prescriptions before the drug plan will pay it’s share. Deductibles vary between plans, and not all plans have deductibles.
What is the loss ratio standards for Individuals?
65%
QMB: Dual Eligible means...
They qualify for both Medicare and Medicaid
When must the Outline of Coverage be given?
Must be given at time of agent solicitation before presentation of application or with application if direct response
What Medicare Savings Program helps pay only the Part B Premium?
Specified Low-Income Medicare Beneficiary (SLMB)
What are the exclusions for Skilled Nursing Care?
Private Room and non-medical services
When would Ambulance Transportation be covered under Part B?
In a medical emergency; only covered in non-emergency situations with a written order from a doctor stating that it is medically necessary
What are one of the three characteristics that go with your HMO Plan?
- Prescription drug coverage usually is included
- Beneficiary must choose a primary care physician
- Referral is required to see a specialist in most cases
Minimum Standards: What is Catastrophic Coverage?
Once the maximum out-of-pocket is paid for the year, the coverage gap is closed and the individual automatically receives catastrophic coverage, requiring a small copayment or coinsurance percentage for covered drugs for the remainder of the year.
What is the only exclusion that is allowed in a Medicare Supplement Policies?
6-month pre-existing condition clause
- Cash
- Money in checking or savings accounts
- IRAs and other retirement plans
- Stocks, bonds, and other investments
- Cash value of life insurance policies
What are the three types of nonforfeiture options?
- Cash Surrender
- Reduce Paid-up
- Extended Term
Medicare beneficiaries who obtain services from non-participating providers are protected by a rule. What is that rule?
Prohibits non-participating providers from charging in excess of 15% of the Medicare-approved charge
For Skilled Nursing Facility Care, what are the 2 benefit periods, and who pays?
1) Days 1-20 Medicare pays the entire cost
2) Days 21-100 Beneficiary pays a daily copayment, Medicare pays the rest
Kenneth met his deductible for Part B. He received covered services for which he was billed $200, which is the Medicare-Approved for those services. How much of the bill will Medicare pay, how much will Kenneth have to pay?
$160/$40
There are four main types of Medicare Advantage plans. (Name 3)
1) Health Maintenance Organization Plans
2) Preferred Provider Organization Plans
3) Private Fee-for-Service Plans
4) Special Needs Plans
Under Employer-Sponsored Retiree Plans, who is eligible?
Everyone with Medicare is eligible for Medicare prescription drug coverage, including retirees and their family members who have Medicare but are covered by employer-sponsored group health plans that offer prescription drug coverage.
In regards to compensation for Medigap policies, the 1st year commission should be no more than _______
200%
What is the definition of Medicaid?
Medicaid provides health coverage to eligible Americans of all ages, including low-income adults, qualified pregnant people and children under age 21, elderly adults age 65 and over, the blind, people with disabilities, those receiving Medicare, and those in need of long-term care.
What does Skilled Nursing Care provide?
Provided in a Skilled Nursing Facility. State licensed operating 24 hours by RN by order of doctor
Donald is Turned 65 in April. He enrolled in Medicare Part A and B during his initial enrollment. He enrolled in February, when is his coverage effective?
Donald's coverage is effective March 1st
For Inpatient Hospital Care, What are the 3 benefit period, and who pays?
1) Days 1-60 Medicare pays everything
2) Days 61-90 Beneficiary pays a daily copayment, Medicare pays the rest
3) Days 91-150 If available, Beneficiary pays a daily copayment, Medicare Pays the rest
Suzanne lives in Florida, for a week she spent time in Puerto Rico. While on vacation, she went to the doctor for the flu. Would her Part B Medicare cover her?
Yes, Puerto Rico is part of the U.S. Territories
June has a Medicare Advantage plan that covers her prescription drugs, she is free to choose any provider, but it is cheaper if she stays in-network. In order to see a specialist, she can just set up an appointment, there is no need to get a referral. What type of plan does she have?
Preferred Provider Organization
If I want a Medicare Advantage plan, am I allowed to purchase a stand-alone plan for my prescription drugs?
Beneficiaries who have Medicare Advantage are generally not allowed to purchase stand-alone plans even if their Medicare Advantage plan does not include prescription drug benefits.
In regards to Premiums, what is the difference between Attained Age and Age at Issue
Based on Attained Age (start lower but increase annually) or Age at Issue (start higher but remain at that level throughout)
What is Medicare Aid?
Medicare-Aid is a free Medicaid program for Medicare recipients who also have limited income and resources. The program can help beneficiaries pay for Medicare premiums, copayments and deductibles.
What does Custodial Care provide?
Personal care that can be provided by someone without med training. Includes assistance with ADLs
In January 2012 Jerry was eligible for Medicare Part A and Part B. Jerry was healthy and decided not to enroll in Part B. Later in January 2015 during General Enrollment Period, Jerry decided that he needed Part B and enrolled. When would his coverage be effective, and what is the % of the penalty for late enrollment in Part B?
His coverage would be effective July 1st, the penalty is 30%
Mark enters the hospital on July 12th, he was discharged on July 25th. Later on August 10th, he was readmitted for the same cause and discharged on September 2nd. How many days does Mark have to pay for?
0, Even though Mark's benefit period did not restart, he was only in the hospital for a total of 38 days. Stay 1 =14
Stay 2 =24
A doctor bills Medicare $1,500 for a procedure, but under Medicare’s payment schedule the approved amount for the procedure is $700. Medicare will pay the doctor 80% of the Medicare-approved amount which is ____ and the beneficiary's coinsurance amount is _____
$560 (80% of $700)/ $140 (20% of $700)
Joseph is 72, he has had the same plan for the last 5 years. Fed up with the plan that he currently has, he wants to get a new plan but isn't sure when he can switch back to Original Medicare. What two time frames can he do this?
Between January 1 and February 14 or October 15 and December 7
Jerry is eligible for Part D coverage, but at that time he doesn't sign up for it. 10 months later he decides he needs it. He is charged with a late enrollment penalty. What would his penalty be?
10% of the year's national base Part D premium.
(1% of the year's national base Part D Premium multiplied by the number of full months that the beneficiary delayed enrollment after first becoming eligible)
Name one of the Core Benefits in a Medicare Supplement Policy
- Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period
- Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used (60 days)
- All costs of the Medicare Part A eligible expenses for hospitalization for a nonrenewable lifetime maximum benefit of an additional 365 days, after all reserve days have been exhausted
- The reasonable cost of the first 3 pints of blood
- Coverage for the coinsurance amount of Medicare eligible expenses under Part B after the Medicare Part B deductible has been met
- Part A Medicare eligible hospice care and respite care coinsurance or copayment
Jennifer is applying for Medicaid, while figuring out her assets, when it comes to her jewelry and clothing, is that a countable or non-countable asset?
Non-Countable Asset
Why is a Financial/Suitability worksheet completed?
Each provider must use standards to determine whether the purchase or replacement of LTC insurance is appropriate for applicant needs