chapter 8

medicare

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 benefits for 2 ye

originial medicare

part A- hospital insurance and part B- medical insurance
overs health care from any doctor, health care provider, hospital or facility that accepts Medicare patients. It usually does not cover prescription drugs. Original Medicare does not require the pat

actual charge

the amount a physician actually bills for a particular service or supply

ambulatory surgical services

care that is provided at an ambulatory center. surgical services performed at a center that do not require a hospital stay unlike in-patient hospital surgery.

approved amount

amount that 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.

comprehensive outpatient rehabilitation facility services

Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.

excess charge

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

maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment.

qualifications for part A medicare, hospital coverage

A citizen or a legal resident of the United States age 65 or over and qualified for Social Security or Railroad retirement benefits � Aged;
Is 65 years old or over and entitled to monthly Social Security benefits based upon the spouse's work record, and t

3 options to sign up for medicare

nitial enrollment period: when an individual first becomes eligible for Medicare (starting 3 months before turning age 65, ending 3 months after the 65th birthday);
General enrollment period: between January 1st and March 31st each year; Special enrollmen

inpatient hospital care

Hospital insurance helps pay for up to 90 days in a participating hospital in any benefit period, subject to a deductible. The first 60 days are covered at 100% of approved charges after the deductible is met. The next 30 covered days are paid, but they a

skilled nursing facility care

Part A helps pay for up to 100 days in a participating skilled nursing facility in each benefit period, following a 3-day inpatient hospital stay for a related illness. To get this type of care, the insured's doctor must certify that daily skilled care is

home health care

For an individual confined to the home and meeting certain other conditions, hospital insurance can pay the full approved cost of home health visits from a participating home health agency. There is no limit to the number of covered visits

part B medical insurance

ays for doctor's services and a variety of other medical services and supplies that are not covered by hospital insurance.
optional and offered to everyone who enrolls in Part A. Part B is funded by monthly premiums and from the general revenues of the fe

medicare under part B does not cover

Private duty nursing;
Skilled nursing home care costs over 100 days per benefit period; Intermediate nursing home care;
Physician charges above Medicare's approved amount;
Most outpatient prescription drugs;
Care received outside the United States;
Custod

part C: medicare advantage

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 programs.
To be

medicare private fee for service plan

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 ge

part D prescription drug benefit

optional coverage is provided through private prescription drug plans (PDPs) that contract with Medicare. To receive the benefits provided, beneficiaries must sign up with a plan offering this coverage in their area and must be enrolled in Medicare Part A

catastrophic coverage

will cover 95% of prescription drug costs.

medigap

designed to fill the gap in coverage attributable to medicares deductibles, copayment requirements and benefit periods

OBRA (omnibus budget reconciliation act)

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 law was to eliminate question