Social Health Insurance

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Social Health Insurance is

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health coverage subsidized and implemented through government administration of tax money and social programs

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Medicare is

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a federal program administered by the Health Care Financing Administration (HCFA).

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Intermediaries are:

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the insurance companies that handle claims for hospitals, skilled nursing facility, home health agencies and hospice services

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Carriers are:

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the insurance companies that handle claims for physician services.

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Medicare benefits are divided into two parts:

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1. Part A, Hospital Insurance

2. Part B, Supplementary Medical Insurance

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Which is voluntary in medicare:

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Part B is voluntary and requires payment of a monthly premium (cost sharing)

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When are you eligible to be automatically enrolled in Part A Medicare:

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the first day of the month in which you reach the age of 65.

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When you are enrolled automatically in Part A what must you do in regards to Part B

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You will be enrolled and premium payments established unless you sign a form indicating you do not want Part B.

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If you do not sign up for Part B is that permanent?

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No - a "general enrollment period" occurs every year from 1/1 through 3/31 and coverage beginning the following July 1.

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4 types of Benefits under Medicare Part A:

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1. Inpatient hospital care

2. Skilled nursing facility care

3. Home health care

4. Hospice care

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Inpatient Hospital Care benefit periods:

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Begins upon admission and ends 60 days after discharge. From 61-90 medicare pays all all but a specified coinsurance. Longer than 90 days you can draw upon 60 lifetime reserve days but the co payment increases substantially with these days.

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Readmission during the 60 days

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is considered part of the same benefit period. Readmission after the 60 days run out is the beginning of a new benefit period.

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Skilled Nursing Facility Care benefit period:

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Up to 100 days in each benefit period. Coinsurance is required for the 21-100 days. The first 20 days Medicare pays all reasonable charges.

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The benefits for skilled nursing facility are narrow:

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Must be receiving medically necessary services by a skilled staff in a medicare-approved facility, following a prior hospital stay of at least 3 days. Intermediate or custodial care is not covered.

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Is Home Health Care have the same benefits as that found in long-term care policies

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NO

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Eligible expenses for Home Health Care are:

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1. Intermittent, part-time nursing care

2. PT, OT, ST

3. Home Health Aides

4. Medical Social Services

5. Medical Supplies

6. 80% of durable medical equipment

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What expenses are not covered with Home Health Care:

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1. Housekeeping

2. Meal prep

3. Meal delivery

4. Shopping

5. Full time Nursing Care

6. Blood Transfusions

7. Drugs or Biological's

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Hospice Care is primarily for:

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providing support services to terminally ill patients and their families

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What is the time frame for Hospice Care :

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It is possible for unlimited period of care as long as a physician certifies need. medicare pays virtually all costs for hospice with no deductible.

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What are the only 2 services in Hospice that require a co-payment:

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1. Prescription drugs - patient pays 5% or $5 per prescription whichever is less

2. Respite Care - 5% of the medicare approved rate up to a specified dollar amount

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What does Part A not cover:

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1. Private duty nursing

2. Charges for a private room, unless medically necessary

3. Conveniences, such as a telephone or television

4. The first 3 pints of blood received during a calendar year.

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3 Types of benefits under Medicare Part B:

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1. Doctor's services

2. Home Health Care (if not covered by Part A)

3. Outpatient Medical Services and Supplies

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Under Part B the patient is responsible for 3 co payments:

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1. annual deductible amount

2. 20% of all reasonable charges for covered, medically necessary services

3. the first 3 pints of blood

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Assignment:

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That the doctor or supplier will accept medicare's approved amounts as full payment and cannot legally bill the patient for anything above that amount,

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Are you required to participate in Part A

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No you can participate in part B only. Remembering that Part B you have a cost

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Part B - Home Health Care

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If a person participates in Part B and not in Part A, Part B pays the full cost of medically necessary home health visits. No deductible or coinsurance except the 20% of the cost of durable medical equipment.

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What Part B does not cover:

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1. Private Duty Nurse

2. Skilled Nursing Home care costs over 100 days per benefit period

3. Intermediate Nursing Home Care

4. Most outpatient prescription drugs

5. Care received outside the US

6. Custodial care received in the home

7. dental, eye, hearing, foot care

8. expenses incurred due to war or acts of war

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What is a Medigap policy

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A medicare supplement insurance policy (that must offer a basic core of benefits) that can help cover the costs not paid by medicare. Under Federal law, only 10 standardized types of policies may be offered.

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What must be included in the core benefits of a medigap policy:

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1. Part A copayments for teh 61-90th day of hospitalization

2. Part A co payments for the 60 lifetime reserve days

3. all charges for 365 days of hospitalization after all Part A inpatient hospital and lifetime reserve days are used up

4. blood deductible (first three pints)

5. Part B co payments on medicare approved charges for physicians and medical services

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What is another version of the standard Medigap policy:

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Medicare SELECT. It is operated on a preferred provider basis. and generally have lower premiums.

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HMO

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Health Maintenance Organization (a Medicare+Choice) option

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PPO

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Preferred Provider Organizations (network of providers who contract to provide services at pre-negotiated rates.

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PSO

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Provider-Sponsored Organizations (owned and operated by the providers themselves and work much like an HMO.

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Medicare managed care plans are either risk or cost plans. The difference is:

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Rick contracts have "locked in " requirements. If you go outside the network neither the plan or Medicare will pay. Cost contracts allow you to go anywhere. Going outside the network, the plan will not pay but Medicare will pay its share.

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When you have medicare and employer coverage medicare may be the secondary payer to any group health plan provided by an employer with:

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20 more more employees

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What is Medicaid?

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A welfare, health care program for indigent persons. It was established by the federal government but is administered by the states.

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Who qualifies for medicaid:

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1. Aid for Families with Dependent Children (also know as public assistance or welfare)

2. Supplemental Security Income for indigent persons who are over age 65, blind or disabled.

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Medicaid limits financial resources

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Recipient must spend down or exhaust his or her income and resources to a minimal amount before medicaid becomes available. You are allowed to keep your home.

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Spousal Impoverishment Rule

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When one spouse requires nursing home care, the law provides that the spouse who is not institutionalized is permitted to keep a portion of the couple's resources.

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In the case of indigent persons the law requires Medicare to pay:

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1. Medicare deductibles

2. Part B premium

3. Medicare co payments

4. Part A premiums (when required)

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Social Security Disability requirements:

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1. Totally and permanently disabled for at least 5 months

2. Expected to be disabled for 12 months or longer or the disability will end in death

3. Fully insured and disability insured as defined under the SS regulations

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What is the PIA -

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Primary Insurance Amount - the benefits available are equal to 100% of the individual's PIA for SS Disability.

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What is Tricare and who receives the benefits

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A regionally managed health care program for active duty and retired members of the military uniformed services and their families, as well as survivors who are not eligible for medicare.

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List the 3 types of Tricare available:

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Tricare Standard - a fee for service plan

Tricare Extra - preferred provider plan

Tricare Prime - those seeking care at Military Treatment Facilities (MTF's)

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What are the benefits that come with Workers Compensation (benefits are not provided directly by the government but are mandated by law):

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1. Disability (loss of income)

2. Medical benefits

3. Survivor (death) benefits

4. Rehabilitation benefits

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How does an injury meet the compensate criteria:

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1. It must be accidental

2. It mus arise out of the individual's employment

3. It must arise in the course of the individual's employment

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What classifies an occupational disease:

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Under workers compensation teh disease must meet these requirements:

1. arise out of employment

2. be due to causes or conditions characteristics of your occupation or trade.

It does not cover ordinary diseased to which the general public is exposed to.

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What are the 4 types of disability under workers compensation law;

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1. Permanent Total

2. Permanent Partial

3. Temporary Total

4. Temporary Partial