Medicare
medicare is a federal medical expense insurance program for people age 65 and older even if the individual continues to work. Medicare benefits are also available to anyone, regardless of age, who has been entitled to Social Security disability income ben
Nature, Financing, and Administration
Medicare is adminstered y the center for medicare and medicaid services, which is a division of the united states department of health and human services. Medicare has four distinct parts: A) hospital insurance, is financed through a portion of the payrol
Medicare Part B
pays for doctor's services and a variety of other medical services and supplies that are not covered by hospital insurance. Most of ther services needed by people with permanent kidney failure are covered only by medical insurance
Individual Eligiblility Requirements - B
optional and offered to everyone who enrolls in Part A. B is funded by monthly premiums and from the general revenues of the federal government
Enrollment - B
When you become eligible for Part A, you are told that you will get and have to pay for Part B unless you decline it. If you later decide you want part B after initially declining it, you must wait until the next general enrollment period (Jan 1 - March 3
Part C - Medicare and Choice
The medicare modernization act of 2003 changed the name of part C from meidcare+choice to Medicare Advantage. Mediare advantage is Medicare provided by an approved Health Maintenance Organization or Preferred Provider Organization. Many HMOs or PPOs do no
Part D - Prescription Drug Insurance
the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was passed in November 2003. This act implemented a plan to add a Part D - Prescription Drug Benefit to the standard Medicare Coverages. Part D was effective on January 1, 20
Primary, Secondary Payor
While an individual becomes eligible for Meidcare upon turning age 65, federal laws extend primary coverage benefits under the employer's plan to active older employees regardless of age. In other words, employer plans continue to be primary coverage and
Medicare Supplements - Purpose
Medicare supplement plans, referred to as Medigap, are policies issued by private insurance companies that are designed to fill in some of the gaps in Medicare. Theese plans are designed to fill the gap in coverage attributable to Medicare's deductibles,
Medicare Supplements - Open Enrollment
Anyone who qualifies for medicare may also purchase a Medicare supplement and pay the necessary premium for those additional benefits. Under OBRA, Medicare supplement insurance may not discriminate in pricing or be denied on the basis of an applicant's he
Medicare Supplements - Rating of Medicare Supplement Plans
Insurance companies may set their own premiums for medicare supplement insurance policies such as Medigap. The policies can be priced or rated in 3 different ways: by attained age (the age of the insured at a determined time); by issue age (the insured's
Standardized Medicare Supplement Plans
In order to standardize the coverage provided under Medicare supplement policies, the NAIC has developed standard Medicare Supplement benefit plans which are idnetified with the letters A through L. The core benefits found in Plan A must be offered in all
Right to Return (free look)
All medicare supplement policies must contain a 30 day free look period where teh insured may return the policy for a complete refund for any reason
Disabled Employees
The Omnibus Budget Reconciliation Act of 1990 requires that large group health plans (100+) must provide primary coverage for disable individuals under age 65 who are not retired
Employees with Kidney Failure
The OBRA as ammended by the Blanced Budget Act of 1997 requires the employer health plan to provide primary coverage for 30 months for individuals with end-stage renal (kidney) disease before Medicare becomes primary
Long term Care (LTC) policies
can be marketed in the form of individual polices, group policies, or as riders to life insurance policies, provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or in a nursing home
LTC, Medicare, and Medicaid Compared
Although Medicare and Medigap policies provide elderly insureds with protection against the cost of medical care, these programs do not provide coverage for long-term custodial or nursing home care
Eligibility for benefits
Normally to be eligible for benefits from a long-term care policy, the insured must be unable to perform some of their "activities of daily living" (ADLs). ADLs include mobility, bathing, dressing, toileting, transferring, continence, and eating. To quali
Levels of Care
Skilled care, intermediate care, custodial care, home health care, adult day care, respite care
Benefit Periods
Long term care policies usually include an elimination period similar to hose found in disability income policies
Benefit Amounts
The benefit amoutn payable under most LTC policies is usually a specific fixed dollar amount per day, regardless of the actual cost of care
Optional Benefits
Guarantee of Insurability, Inflation protection, nonforfeiture, return of premium
Exlcusions
Long Term care policies may have the following exclusions: pre-exisiting conditions of diseases; mental and nervous disorders or disease; alcoholism and drug addiction; treatment or illness caused by war, participation in criminal activities, or attempted
Underwriting considerations
before a long-term care policy will be issued to an applicant age 80+, the insurer must obtain the following: a report of a physical examination; an assessment of functional capacity; an attending physician's statement; copies of medical records
LTC partnership
allow those who have exhausted or at least used some of their private LTC benefits to apply for Medicaid coverage without having to meet the same means-testing requirements