130876
Description
Flashcards by Det Ferraris, updated more than 1 year ago
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Created by Det Ferraris
over 12 years ago
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| Question | Answer |
| Medicare | Government Health Insurance primarily for people 65 and older. |
| Generally, one must be fully insured (40) to be eligible for Medicare. | Generally, one must be fully insured (40) to be eligible for Medicare. |
| People eligible for Medicare | 65+ eligible for SS, 65+ NOT eligible for SS but willing to pay premium, any age SS disability recipient for 2 years, Any age with end state kidney disease |
| Public Assistance Recipients (Welfare) are NOT eligible for Medicare | Public Assistance Recipients (Welfare) are NOT eligible for Medicare |
| Medicare Part A= Hospital Coverage | Medicare Part A= Hospital Coverage |
| Medicare Part B= Medical Coverage | Medicare Part B= Medical Coverage |
| I went to A hospital to B seen by a doctor | I went to A hospital to B seen by a doctor |
| Medicare Part A: deductibles, copayments and Coinsurance can apply | Medicare Part A: deductibles, copayments and Coinsurance can apply |
| Part A Cover: | Hospitalization Skilled Nursing Facility Care (limited that why you need LTC ins), Home Health Care, Hospice Care |
| Medicare Part B covers | Medical Expenses, Clinical Laboratory Services, Home Health Care, Outpatient Hospital Treatment |
| Medicare Part B: $135 Annual Deductible 80/20 Coinsurance | Medicare Part B: $135 Annual Deductible 80/20 Coinsurance |
| Part A is FREE if fully insurable | Part A is FREE if fully insurable |
| Part B= monthly premium | Part B= monthly premium |
| You are enrolled in Medicare Part A and B @ 65 if receiving SS benefits. | You are enrolled in Medicare Part A and B @ 65 if receiving SS benefits. |
| Enrollment in Part B can be delayed by someone who is covered under a group health plan based on the active employment of... | Individual, Spouse, Parent |
| Initial Enrollment Period (IEP) | 3 months before and after 65th Birthday |
| General Enrollment Period (GEP) | for those who didnt enroll during the Initial Enrollment Period.. Jan 1st - Mar 31st of each year |
| Special Enrollment Period (SEP) | allows enrollement if enrollment delayed because of group coverage. |
| Part A Funding | Funded by Payroll Tax, Pay as you go system |
| Part B | funded my monthly premiums |
| Medicare Advantage Plans (Part C) | medicare approved health plan options managed by private insurance companies. includes: Parts A &B, hearing, vision, dental, wellness programs, prescription drugs |
| Private Fee For Service (PFFS) Free to choose providers, No restrictive networks, No referrals needed | Special Needs Plan (SNP) provides specialized care for chronic conditions, disabling conditions, nursing home residents |
| Demonstrations | special Medicare Advantage Plans that tests improvements in Medicare coverage, payment, and quality of care |
| Medicare Prescription Drug Coverage (Part D) | Medicare-approved OPTIONAL prescription drug plans run by insurance companies and other private companies |
| Part D can be added for an additional premium to: | Original Medicare Plan (Parts A & B), Medicare Advantage Plan (Part C) |
| Late penalty added to Part D premium if purchased AFTER initial enrollment period for coverage | Late penalty added to Part D premium if purchased AFTER initial enrollment period for coverage |
| penalty avoided if NO MORE THAN 63 DAYS pass without CREDITABLE COVERAGE following initial enrollment period. | penalty avoided if NO MORE THAN 63 DAYS pass without CREDITABLE COVERAGE following initial enrollment period. |
| Creditable Coverage | drug coverage from employer, union, Tricare, |
| Con-Creditable Coverage | drug coverage that, on average, is NOT expected to pay out as much as standard Medicare prescription drug coverage |
| Annua Enrollment Period (AEP) | Nov 15- Dec 31 which eligible individual can join or switch Medicare Advantage Plan (Part C) or Medicare Drug Plan (Part D) New Coverage begins on January 1st of the following year. |
| Open Enrollment Period (OEP) | period from Jan 1- Mar 31 in which Medicare beneficiary can enroll, disenroll from, or change a Medicare Advantage plan Changes are effecting the FOLLOWING MONTH Drug Coverage cannot be added or dropped during Open Enrollment |
| Approved Amount | maximum amount Medicare will pay a doctor or provider |
| Medicare Assignment | agreemement where patients "assigns" Medicare to pay his doctor/provider directly for services performed |
| Medicare Assignment | agreemement where patients "assigns" Medicare to pay his doctor/provider directly for services performed |
| If provider accept ASSIGNMENT they agree to: | only charge patient for dedutibles, coinsurance and copayments, accept Medicare's approved amount, submit claims to and be paid by Medicare |
| Medicare benefits CAN be assigned to an HMO OR PPO | Medicare benefits CAN be assigned to an HMO OR PPO |
| Participating Physician | ALWAYS accepts assignments |
| Non-Participating Physician | Can accept assignment on CASE-BY-CASE basis |
| Medicare claim is started when medical provider contacts (bills) Medicare | Medicare claim is started when medical provider contacts (bills) Medicare |
| Medical Summary Notice (MSN) AKA Explanation of Benefits | detailed notice sent to a Medicare recipient in the Original Medicare Plan after a doctor or provider files a claim for Part A or Part B services |
| Medicare recipient can appeal ANY claims decision | Medicare recipient can appeal ANY claims decision |
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