Medicare
a federal medical expense insurance program for people AGE 65 and older even if the individual continues work. benefits are also available to anyone, REGARDLESS OF AGE, who has been entitled to Social Security disability income benefits for 2 years or has
4 Parts of Medicare
1. Part A (Hospital Insurance) is financed through a portion of the payroll tax (FICA)
2. Part B (Medical Insurance) is financed from monthly premiums paid by insureds and from the general revenues of the federal government
3. Part C (Medicare Advantage)
Original Medicare
refers only to Part A and Part B. it covers health care from any doctor, health care provider, hospital or facility that accepts Medicare patients. It usually does not cover prescription drugs. does not require patients to choose a primary care doctor nor
Medicare Part A-Hospital Insurance
helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care.
eligible if...
have ESRD
have ALS
disabled for 24 months (been on SS)
over 65
65, good work record, spouse is 62
initial enrollment period
when an individual first becomes eligible for Medicare (starting 3 months before turning 65 ending 3 months after their 65th bday)
general enrollment period
between Jan 1 and March 31 each year
Special enrollment period
at any time during the year if the individual or their spouse is still employed and covered under a group health plan
Medicare Part B-Medical Insurance
pays for doctor's services and a variety of other medical services and supplies that are NOT covered by hospital insurance. Most of the services needed by people with permanent kidney failure are covered only by medical insurance.
Part B eligibility
Part B is optional and offered to everyone who enrolls in Part A. Part B is funded by monthly premiums and from the general revenues of the federal government Most people enrolled in Part B pay the standard monthly premium. However, if an insured's modifi
actual charge
the amount a physician or supplier actually bills for a particular service or supply
ambulatory surgical services
care that is provided at an ambulatory center. these are surgical services performed at a center that do not require a hospital stay unlike in-patient hospital surgery.
approved ammount
the amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare
assignment
the physician or a medical supplier agrees to accept the Medicare-approved amount as full payment for the covered services
carriers
organizations that process claims that are submitted by doctors and suppliers under Medicare
coinsurance
the portion of Medicare's approved amount that the beneficiary is responsible for paying
comprehensive outpatient rehabilitation facility services
outpatient services received from a Medicare participating comprehensive outpatient rehab facility
deductible
the amount of expense a beneficiary must first incur before Medicare begins payment for covered services
durable medical equipment
medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home
excess charge
the difference between the Medicare approved amount for a service or supply and the actual charge
intermediaries
organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services
limiting charge
the maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment
nonparticipating
doctors or suppliers who may choose whether or not to accept assignment on each individual claim
outpatient physical and occupational therapy and speech pathology services
medically necessary outpatient physical and occupation therapy or speech pathology services prescribed by a doctor or therapist
pap smear screening
provides for a pap smear to screen for cervical cancer once every 2 years
partial hospitalization for mental health treatment
a program of outpatient mental health care
participating doctor or suppliers
doctors and suppliers who sign agreements to become Medicare-participating. For example, they have agreed in advance to accept assignment on all Medicare claims
peer review organizations
groups of practicing doctors and other health care professionals who are paid by the government to review the care given to Medicare patients
Medicare Part C-Medicare Advantage
these plans must cover all of the services covered under the Original Medicare except hospice care and some care in qualifying clinical research studies. It may also offer extra coverage, such as vision, hearing, dental, and other health and wellness prog
eligibility for Part C
beneficiaries must be enrolled in Medicare Parts A and B. Part C is provided by an approved HMO or PPO.
Medicare Private Fee-for-Service Plan
a Medicare Advantage Plan offered by a private insurance company. Medicare pays a set amount of money every month to the private insurance company to provide health care coverage. The insurance company decides how much enrollees pay for the services they
Special Needs Plans (Part of Part C)
provides more focused and specialized health care for specific groups of people. This includes people who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions
Medicare Part D (Prescription Drug Insurance)
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was passed in November 2003. This act implement a plan to add Part D to the standard Medicare Coverages. This OPTIONAL coverage is provided through private prescription drug
donut hole
Medicare part D coverage gap. once the benefit limit is reached, now the beneficiary is responsible for a portion of prescription drug costs.
catastrophic coverage
if the beneficiary's spending during the gap reaches the limit of coverage gap, this kicks in. it will cover 95% of prescription drug costs. The beneficiary pays the greater of the specified amount or 5%. the cost limit for generic drugs would be lower th
Medigap (Medicare Supplement plans)
policies issued by private insurance companies that are designed to full in some of the gaps in Medicare. These plans are designed to fill the gap in coverage attributable to Medicare's deductibles, copayment requirements, and benefit periods.
Omnibus Budget Reconciliation Act of 1990 (OBRA)
Congress passed a law that authorized the NAIC to develop a standardized model for Medicare supplement policies. this model requires Medigap plans to meet certain requirements as to participant eligibility and the benefits provided. The purpose of this la
open enrollment period
6 month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare Part B. In essence, to buy a Medigap policy, the applicant must generally have both Medicare Part A and B
core benefits (of Medicare Supplement Plan A)
-Part A coinsurance/copayment (NOT part A deductible)
-Part A hospital costs up to an additional 365 days after Medicare benefits are used up
-Part A hospice care coinsurance/copayment
-Part B coinsurance/copayment
-the first 3 pints of blood ("Blood dedu
Plan B
Core benefits PLUS Medicare Part A deductible
Plan C
core benefits, Medicare part A deductible, skilled nursing facility coinsurance, Medicare Part B deductible and the foreign travel benefit
Plan D
core benefits, Medicare part A deductible, skilled nursing facility coinsurance, and the foreign travel benefit
Plan F
core benefits, Medicare part A deductible, skilled nursing facility coinsurance, Medicare Part B deductible, 100% of Medicare Part B excess charges and the foreign travel benfit
Plan G
core benefits, Medicare part A deductible, skilled nursing facility coinsurance, 100% of Medicare Part B excess charges, and the foreign travel benefit. This plan must pay for services of activities of daily living (ADL) that Medicare doesn't cover
Medicaid
a federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care. Individual states design and administer the Medicaid programs (typically through the state's Department of Public Welfare)
Medicaid mandated benefits
-physician's services
-inpatient hospital care
-outpatient hospital care
-skilled nursing home services
-laboratory and x-ray services
-home health care services
-rural health care services
-periodic screening, diagnosis, and treatment
-family planning se
ConnMAP
assures CT's lower-income Medicare Part B enrollees that health care providers who agree to treat them will not charge them more than Medicare-approved rates for services covered by Medicare Part B
(eligibility: 65+ or disabled over age 18)
ConnPACE
The Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled was created to help eligible senior citizens and the disabled afford prescription medicines. To be eligible, an individual must be a CT resident age 65+ or be disabled at age 1
Long-term care (LTC) 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 facility.
-must provide coverage for at least 12 consecutive months in a setting other than an acute care u
skilled care
daily nursing and rehabilitative care that can only be provided by medical personnel, under the direction of a physician. Skilled care is almost always provided in an institutional setting. Examples of skilled care include changing sterile dressing and ph
intermediate care
occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis than skilled nursing care. It is ordered by a physician and skilled medical personnel would deliver or monitor the type
custodial care
care for meeting personal needs such as assistance in eating, dressing, or bathing which can be provided by non-medical personnel, such as relatives or home health care workers. it can be provided in an institutional setting or in the patient's home. it i
home health care
care provided by a skilled nursing or other professional services in one's home. includes occasional visits to the person's home by RNs, licensed practical nurses, licensed vocational nurses or community-based organizations like hospice. might include PT,
adult day care
care provided for functionally impaired adults on less than a 24-hour basis. It could be provided by a neighborhood recreation center or a community center. Care includes transportation to and from the day care center, and a variety of health, social and
respite care
designed to provide relief to the family caregiver, and can include a service such as someone coming to the home while the caregiver takes a nap or goes out for a while. Adult day care centers also provide this type of relief for the caregiver.
hospice care
a facility that provides short-term, continuous care in a home-like setting to terminally-ill people with life expectancies of 6 months or less.
Connecticut Partnership for Long Term Care
a cooperative effort among insurers, the Department of Social Services and the Insurance Department to combine private insurance and Medicaid funds to finance long-term care. Under this program, an individual may purchase a pre-certified long-term care in