Medicare Advantage and Supplemental Plans, Exams of Study of Commodities

Download Medicare Advantage and Supplemental Plans and more Exams Study of Commodities in PDF only on Docsity! Study Guide for North Carolina Medicare Supplement-Long Term What is Medicare? - Answer - Government health insurance program for people over 65 or younger people who may qualify. Who under 65 may qualify for Medicare? - Answer - Individuals who have disabilities such as permanent kidney failure or ALS Medicare part A covers what? - Answer - Hospital Which part of Medicare covers medical insurance? - Answer - Part B Which part of Medicare is known as Medicare Advantage? - Answer - Part C What criteria must be met to qualify for enrollment in Medicare Advantage - Answer - Must be enrolled in Part A & B Which part expands Original Medicare Benefits through Private Health Insurance Programs? - Answer - Part C Which part of Medicare covers prescription Drugs? - Answer - Part D Medicare parts A and B are administered only by whom - Answer - The Federal Government How many Medicare savings programs are there - Answer - 4 How are persons who are age 65 or older who do not participate in Social Security eligible for Medicare? - Answer - If premium is paid Is Medicare Part B a voluntary health insurance program? - Answer - Yes What does the limited Medicare savings program MQB-B Pay for? - Answer - (Part B Premium Only) To participate in Medicare a person must be what? - Answer - A US citizen or a permanent legal resident) When does the initial enrollment period for Medicare Part B begin? - Answer - 3 months before the month that the enrollee turns 65 For employers with 20 or more employees who offer group converge, would Medicare be considered the primary or secondary coverage? - Answer - Secondary What does the acronym PPS stand for? - Answer - Prospective Payment System What is the primary function of the MAC? - Answer - Medical reviews to ensure that services covered are reasonable and necessary) Under which review can a physician submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan? - Answer - (Prospective Review) Medicare Part A allows how many reserve days per lifetime? - Answer - (60) Under Medicare part A how many days can patients get coverage in a Skilled Nursing Facility Coverage in a benefit period? - Answer - Up to 100 Days Are only the first 20 days (about 3 weeks) in a Skilled Nursing Facility covered in full, True or False - Answer - True Skilled nursing care and certain other health care services that a patient receives at home for an illness or injury is defined as what? - Answer - (Home health Care) What does First Dollar Coverage Mean? - Answer - No Deductible Special care for people who are terminally ill is what? - Answer - Hospice Care given to a hospice patient by another caregiver so that the usual caregiver may get a rest is what? - Answer - Respite care How is hospice care administered? - Answer - Two 90 days (about 3 months) periods followed by unlimited 60-day periods) For Medicare to cover skilled nursing, who must recommend the patient needs daily care? - Answer - The Doctor What percentage of the cost of durable medical equipment does Medicare pay? - Answer - (80 %) Under Medicare Part A, who pays for the first 3 pints of Blood? - Answer - The patient What is the Medicare Summary Notice known as? - Answer - EOMB or the EOB How much is the Hospice drug benefit copayment for Pain relief drugs. - Answer - ($5) What is the maximum number of days that Medicare will pay for inpatient mental health care? - Answer - 190 Days What are the 4 types of MA Plans? - Answer - HMO, PPO,PFFS, Snp's Long Term Care is Primarily - Answer - Personal Care-ADL Skilled Care - Answer - medically necessary services ex :changing dressing medicaid - Answer - low income Guaranteed Renewable - Answer - All long-term care policies must be guaranteed renewable, which means the policy be renewed as long as the insured is paying the premiums, but the premium may by increased as the insured ages. Prospective Payment System (PPS) - Answer - 3 diagnosis- Hospital Inpatient, Hospital Outpatient, Physician Payment(no drug payment) Eligibility for Medicare Supp - Answer - 65 & Part A & Part B; Medicare Part B deductible benefit period - Answer - Benefit period is one year Primary Function of MAC - Answer - Review and ensure that services are covered reasonably and necessary Homemaker Services - Answer - household services done by someone else b/c the patient is unable to do them.(Including nursing services, personal hygiene, house chores, errands, and preparation of meals, laundry and limited house maintenance.) Every insurer providing Medigap policies or certificates in NC is required to file the policy's rates, rating schedules and supporting documents, This information must be filed - Answer - annually Medicare Hospice Care benefit will pay for all the following except - Answer - Care in an emergency room is excluded Home Health Care is - Answer - treatment if an illness or injury, it is not full-time (intermittent) skilled nursing care physical therapy or speech language pathology services No deductible for home health care Medicare Part B will cover services received from a doctor if performed - Answer - Anywhere When doctors and suppliers agree to accept assignment, they accept which of the following as a full payment - Answer - The Medicare approved amount To qualify for skilled care nursing care, a patient must - Answer - Have a qualifying hospital stay of at least 3 consecutive days(not including discharge. Custodial care is not skilled care hospice benefit is for terminally ill patients only What would a physician utilize if they wanted to know if a treatment is covered under an insured's plan and what rate it will be paid? - Answer - Prospective Review- Review of pre-certification provision, physicians can submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan and at what rate it will be paid What is another name for medicare supplement policies - Answer - Medigap-to fill in the gaps in medicare What is excluded from coverage under Medicare Part B - Answer - Custodial Care received at home Under a Medicare PPO plan, if a patient covered chooses to see an Out-of Network provider, the cost to the patient will be Higher or lower? - Answer - Higher Medicare pays the first 20 days of Skilled Nursing Facility care. For days 21 through 100, medicare pays - Answer - All but 200.00 per day Post-hospital extended care in a skilled nursing facility for up to 100 days in each "benefit period" is covered. The patient pays nothing for the first 20 days.After 20 days, the patient pays coinsurance of 200.00 a day, Persons age 65 or older who do not participate in Social Security are - Answer - Eligible for Medicare if a premium is paid Part A is financed by the Health Insurance tax, a part of payroll withholding tax,deductibles and co payments. In long-term care insurance, bathing,dressing, eating, toileting , continence, and transferring are called - Answer - Activities of daily living(ALD's)-Long Term Care insurance -Personal care means the provision of hands-on services to assist an individual with activities of daily living -Cognitive impairment means a deficiency in a person's short or long term memory Who sets the standards for Medicare Part D plans - Answer - Medicare Respite care can be referred to as - Answer - Care for the caregiver -Respite care gives the primary caregiver a break by providing inpatient respite care The Benefit period for the Medicare Part B deductible is - Answer - 1 year - The benefit period for the Medicare Part B deductible is 1 year How much can an individual deduct from their taxable income on long term care if employed - Answer - 0.00 - a individual under 65 who is not self employed must itemize deductions and have an amount reimbursed medical expenses that exceed the 7.5? figure. Prior to purchasing a medigap policy, a person must be enrolled in which of the following - Answer - Part A & B of medicare -To buy a Medigap policy , the applicant must generally have both parts A&B Which of the following is the main source of health care funding for people with low income - Answer - Medicaid Medicaid is the largest source of health care funding for people with low incomes.Medicare is not restricted to those with low incomes. Only those limited income are eligible for Medicaid Regarding long-term care policies, what is not included in activities of daily living - Answer - Sleeping -ADL's include bathing, toileting, transferring (or mobility) continence and eating.To be eligible for benefits from long-term care policy, the insured must be unable to perform some of the activities of daily living(ADL's) If an insured appeals a service on the Medicare Summary Notice (MSN) and sends a request to the Medicare Administrative Contractor, within, how many will the MAC generally send the decision to the insured - Answer - 60 Days - usually 60 days after receipt of the request. The traditional Pay-pay-visit arrangement available nationwide is known as - Answer - Original Medicare Plan A woman has enrolled in Medicare Part B, effective July 1. She schedules an appointment for a wellness exam on December 1. Medicare Part B will - Answer - Cover the Cost - initial wellness visits within 12 months of the day the persons 1st enrolls in Medicare Part B is covered as well as one wellness exam every 12 months thereafter Medicare-covered hospital expenses include - Answer - Semi-Private Room Meals General Nursing Hospital Services and supplies -critical access hospitals and impatient mental health care. Surgeon Feed are paid from Part B A long-term care policy that is guaranteed renewable means that - Answer - Guaranteed renewable means that the policy must be renewed as long as the insured is paying premiums, but the premiums may be increased -Medigap covers some preventative care and some excess charges known as Part B balance billing for patients who are treated by a provider that does not accept assignment. Medigap covers some of patients cost up to 100 days in a SNF How many consecutive months of coverage must LTC insurance provide in this state? - Answer - 12 months-! year What is the benefit limit max for Part D - Answer - $4,660 -after deductible is met How much is the coinsurance for SNF after say 20? - Answer - 200.00 -21-100 days How much is SNF after 100 days? - Answer - The patient will pay all cost How much is SNF days 1-20? - Answer - Medicare will pay all the cost In NC what is the expected loss ratio for individual long term care insurance at least - Answer - 60% -60% individual -75% for group A NC LTC policy regulation states that no policy may be issued in NC unless it provides for an offer of what? - Answer - Non forfeiture benefit - No policy can be used in NC unless it provides for an offer non forfeiture, which cannot be less than an offer of reduced paid-up insurance, extended term insurance benefit, or a shortened benefit period. When an patient is receiving outpatient dialysis treatment in a Medicare-Approved dialysis facility, the treatment are covered by - Answer - Part B - outpatient dialysis when the patient gets treatment in any Medicare approved dialysis facility is covered by Part B Part A covers INpatient hospital care Regarding long-term care coverage, as the elimination period gets shorter, the premium - Answer - Increases. When the patient is receiving outpatient dialysis treatments in a Medicare-approved dialysis facility, the treatments are covered by - Answer - Medicare Part B. Outpatient dialysis when the patient receives treatments in any Medicare-approved dialysis facility is covered by Medicare Part B. Medicare Part A covers inpatient hospital care. What is the minimum number of renewal cycles on a Medigap policy that an agent must receive compensation? - Answer - 5 years Agents selling Medigap policies must be paid a commission for at least 5 renewal years. A long-term care policy may EXCLUDE coverage for - Answer - Mental disorders. -A long-term care policy may exclude coverage for mental or nervous disorders, except for Alzheimer's disease. What is the penalty to an eligible individual who is still working and covered by group health insurance for enrolling in Part B of Medicare after the initial enrollment period? - Answer - None The special enrollment period is available without penalty if a person is eligible for Medicare based on age or disability but waited to enroll in Medicare Part B because the insured or insured's spouse had group health coverage through an employer. A patient who has Medicare Part A and Medicare Part B is homebound and needs a wheelchair. The chair has been prescribed by a doctor, and a home health care plan has been developed. What percent of the wheelchair cost will be paid by Medicare? - Answer - 80% of the Medicare approved amount after the patient has met the Medicare Part B deductible -Durable medical equipment is paid under Medicare Part B. Patients must satisfy an annual Medicare Part B deductible and pay 20% of the Medicare approved amount. Medicare covers a mammogram screening - Answer - For digital technologies used in the screening. -Medicare covers mammogram screening for all women with Medicare ages 40 and older. The patient pays 20% of the Medicare approved amount with no Part B deductible. Occasional visits by which of the following medical professionals will NOT be covered under LTC's home health care? - Answer - Attending physician -Home health care is care provided in one's home and could include occasional visits to the person's home by registered nurses, licensed practical nurses, licensed vocational nurses, or community-based organizations like hospice. Home health care might include physical therapy and some custodial care such as meal preparations. An insured receives health care through both Medicare and Medicaid. She currently has prescription drug coverage through Medicaid. Does the insured need to enroll in Medicare Part D? - Answer - Yes, she must begin receiving her prescription drug coverage through Part D. -Anyone enrolled in both Medicare and Medicaid, and who receives prescription drug coverage through Medicaid should enroll in Medicare Part D for prescription drug coverage. Those with Medicaid who are not enrolled in Medicare can continue to receive prescription drug coverage through Medicaid patient is admitted to a skilled nursing facility (SNF). The patient does not have a Medigap policy, and the SNF charges $200 per day. The patient is discharged after a 30-day stay. How much would she have to pay? - Answer - $2,000 -The patient will have to pay $200 per day for each day over 20 days of care in a Skilled Nursing Facility. Had the patient purchased a Medigap policy that included the skilled nursing care benefit, the Medigap policy could have paid up to the $200 per day. When a patient is in a facility receiving care at the Medicaid rate and has limited resources, the patient's income must be - Answer - Less than the cost of care at the facility. -Medicaid pays for medically necessary nursing home care for patients in skilled or intermediate care nursing homes or in intermediate care facilities for the mentally retarded. The patient's income must be less than the cost of care in the facility at the Medicaid rate, and there is a limit on resources. The outline of coverage for Medicare supplement policies is - Answer - A summary of the policy applied for or issued. According to nonforfeiture benefit provision in long-term care policies, if an insurer is planning a premium rate increase, the policyholders must be notified within how many days prior to the due date of the new premium? - Answer - 45 days -Insurers must notify policyholders at least 45 days prior to the due date of the premium reflecting the rate increase. Insurers must notify policyholders at least 45 days prior to the due date of the premium reflecting the rate increase. - Answer - The care must be provided as long as the insured is confined as an inpatient in any facility licensed by the state. A man is covered under Medicare Part A. He has a 10-day stay in a Medicare-certified skilled nursing facility which he entered after a 2-day stay in the hospital. The cost per day is $400. How much will this insured have to pay for skilled nursing facility care? - Answer - $4,000 (the entire cost) -the insured will have to pay all costs as he entered the skilled nursing facility after only a 2-day stay in the hospital. Medicare requires a 3-day stay. The traditional pay-per-visit arrangement available nationwide is known as - Answer - Original Medicare Plan. -The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide is called the Original Medicare Plan. A producer has replaced one Medigap policy with another. Both plans have the same benefits. The producer's first year commission is 20%. Her renewal commission is 10%. Both plans are with the same insurer. The producer's first year commission on the new policy is - Answer - 10%. -An insurer cannot provide compensation to agents or other producers that is greater than the renewal compensation that would have been paid on an existing policy if the existing policy is replaced by another policy with the same insurer where the new policy benefits are substantially similar to the benefits under the old policy and the old policy was issued by the same insurer or insurer group.