Medicare
A federal health insurance program for people 65 years of age and older, people of any age suffering permanent kidney failure and people with certain disabilities that have entitled them to Disability Income coverage under Social Security for the past 24
Part A-Hospital Insurance
Free to those eligible - no premium charge, but plan includes deductibles and 80/20 coinsurance for hospitalization, post-hospital skilled nursing care, home-health care, hospice care, and blood transfusions. Part A excludes private rooms (only semi-priva
Part B-Medical Insurance ( Supplementary Medical Insurance (SMI))
An optional part of Medicare that includes deductibles and 80/20 coinsurance for services provided by physicians in or out of the hospital, clinical laboratory services (such as blood tests), home-health care, outpatient hospital treatment and blood trans
Part C-Medicare Advantage Plans
HMO/PPO provided coverage. Can only get Part C if the beneficiary has both Part A & Part B. If the beneficiary buys Part C, then they don't need a Medi-Gap or supplemental policy. Subscribers may have to pay an additional premium for the coverage
Part D-Medicare Prescription Drug Insurance
Optional plan but no one may be denied coverage for health reasons. Includes a deductible and coinsurance. Underwritten by private insurance companies. Fed pays about 75% of the costs and beneficiaries must pay the rest, primarily in monthly premiums. Pla
Capitation
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a pe
Medi-Gap or supplemental policies
To fill the gaps created by Medicare's deductibles and Coinsurance requirements, many private insurers have designed policies to cover some or all of the services not covered by Medicare; have to have Part A & Part B before you can enroll in Medi-Gap poli
Open enrollment period
During these 6 months, I can buy any Medicare supplement policy I want, without regard to my health. Insurance companies have to sell it to me. I can't stop the 6 month enrollment period, and I can't put it on hold. If I wait beyond the open enrollment pe
Medicare Supplement or Medi-Gap disclosure documents
No Medicare Supplement policy may be delivered unless a Buyer's Guide (called "The Guide to Health Insurance for People with Medicare") and a complete printed Outline of Coverage (proposal) is delivered to the applicant prior to the time the application i
Replacement of Medicare Supplement
If the producer is replacing one Medicare supplement with another, the producer must also give the applicant a Notice Regarding Replacement of Health Insurance prior to delivering the policy. In addition, a producer may not sell a Medicare Supplement to a
Free look for Medicare Supplements
All new Medicare Supplement policies must contain at least a 30-day free look, which gives the client 30 days from policy delivery to have all of the premium refunded if not satisfied for any reason
Core benefits
The 12 standard plans include a basic policy offering "core" benefits - Plan A
Medicare SELECT
One of the standardized plans, but it's an HMO product. Medicare SELECT policies will only pay or provide full benefits if covered services are obtained through specified health care professionals and facilities. Medicare SELECT policies will deny payment
Primary or secondary Medicare coverage
If you are 65 or over and you or your spouse work, Medicare may be secondary to any employer group health plan coverage you have. This means that the employer plan pays first. If the employer plan does not cover all your expenses, Medicare may pay seconda
Age discrimination
Employers who have 20 or more employees are required to offer the same health benefits, under the same conditions, to employees and employees spouses who are 65 years of age or older, that they offer to younger employees and spouses
ESRD
Medicare is secondary to Employer Group Health Plans for 30 months for employees or their dependents who have Medicare solely because of permanent kidney failure. After 30 months, Medicare becomes the primary payer
Medicaid
a medical welfare-type program for those with low income and/or no assets. Money is funded by federal, state and local subsidies. Medicaid is NOT part of the Social Security system. Medicaid contracts with health-services providers to provide hospital and
Long-term care insurance
Pays for the kind of care needed for individuals who have a chronic illness or disability, regardless of age. It covers the cost of custodial nursing care, but may also provide coverage
for home based care, including visiting nurses, chore services and re
ADL
Activities for Daily Living including dressing, bathing, feeding,
walking and the general ability to care for oneself
Optional Adult Day Care coverage
Covers transportation to and from a day care center, meals and some medical services for functionally impaired insureds
Optional Hospice Care coverage
Provides coverage for pain control, comfort and counseling for a terminally ill insured and their family at a facility that provides both room and board and medication for pain
Optional Inflation protection coverage
Allows the insured to purchase protection to address the reduction of the value of LTC benefits that may result over a period of time, must be offered to all LTC applicants at the time of purchase in most states
Functional assessment method of risk classification
Whether or not an individual can perform the activities of daily living
LTC waiting period
LTC policies usually contain waiting or elimination periods, often 30 days or longer.
LTC Benefit period
Benefit periods are usually two to five years in duration, with "inside limits" on daily benefit amounts
Alzheimer's disease
Can not be excluded from LTC
LTC Outline of Coverage
An Outline of Coverage (Proposal) and the NAIC Shoppers Guide to LTC insurance must be delivered by the producer to the applicant for LTC at the time of the application, or
if sold by direct response, no later than the time the policy is delivered. Propos
LTC Right to Return (Free Look)
An individual LTC policyholder who purchased his coverage from a producer has the right to return the policy within 30 days of delivery and have all of the premium refunded if not satisfied for any reason
LTC Renewability
All individual LTC policies must be either guaranteed renewable or non-cancelable and such provision must appear on the first page of the policy clearly stating the duration of
renewability
Guaranteed Renewable
The contract must be renewed by the insurer (usually for a certain specified period of time as stated in the contract) if the insured pays the premium. Coverage may not be changed, but rates may be changed by class only
Non-cancelable
The policy may not be cancelled during its life (which is specified in the contract) and nothing may be changed, not even the rates