H5: Medicare

Question	Answer
Medicare	Government Health Insurance primarily for people 65 and older.
Generally, one must be fully insured (40) to be eligible for Medicare.	Generally, one must be fully insured (40) to be eligible for Medicare.
People eligible for Medicare	65+ eligible for SS, 65+ NOT eligible for SS but willing to pay premium, any age SS disability recipient for 2 years, Any age with end state kidney disease
Public Assistance Recipients (Welfare) are NOT eligible for Medicare	Public Assistance Recipients (Welfare) are NOT eligible for Medicare
Medicare Part A= Hospital Coverage	Medicare Part A= Hospital Coverage
Medicare Part B= Medical Coverage	Medicare Part B= Medical Coverage
I went to A hospital to B seen by a doctor	I went to A hospital to B seen by a doctor
Medicare Part A: deductibles, copayments and Coinsurance can apply	Medicare Part A: deductibles, copayments and Coinsurance can apply
Part A Cover:	Hospitalization Skilled Nursing Facility Care (limited that why you need LTC ins), Home Health Care, Hospice Care
Medicare Part B covers	Medical Expenses, Clinical Laboratory Services, Home Health Care, Outpatient Hospital Treatment
Medicare Part B: $135 Annual Deductible 80/20 Coinsurance	Medicare Part B: $135 Annual Deductible 80/20 Coinsurance
Part A is FREE if fully insurable	Part A is FREE if fully insurable
Part B= monthly premium	Part B= monthly premium
You are enrolled in Medicare Part A and B @ 65 if receiving SS benefits.	You are enrolled in Medicare Part A and B @ 65 if receiving SS benefits.
Enrollment in Part B can be delayed by someone who is covered under a group health plan based on the active employment of...	Individual, Spouse, Parent
Initial Enrollment Period (IEP)	3 months before and after 65th Birthday
General Enrollment Period (GEP)	for those who didnt enroll during the Initial Enrollment Period.. Jan 1st - Mar 31st of each year
Special Enrollment Period (SEP)	allows enrollement if enrollment delayed because of group coverage.
Part A Funding	Funded by Payroll Tax, Pay as you go system
Part B	funded my monthly premiums
Medicare Advantage Plans (Part C)	medicare approved health plan options managed by private insurance companies. includes: Parts A &B, hearing, vision, dental, wellness programs, prescription drugs
Private Fee For Service (PFFS) Free to choose providers, No restrictive networks, No referrals needed	Special Needs Plan (SNP) provides specialized care for chronic conditions, disabling conditions, nursing home residents
Demonstrations	special Medicare Advantage Plans that tests improvements in Medicare coverage, payment, and quality of care
Medicare Prescription Drug Coverage (Part D)	Medicare-approved OPTIONAL prescription drug plans run by insurance companies and other private companies
Part D can be added for an additional premium to:	Original Medicare Plan (Parts A & B), Medicare Advantage Plan (Part C)
Late penalty added to Part D premium if purchased AFTER initial enrollment period for coverage	Late penalty added to Part D premium if purchased AFTER initial enrollment period for coverage
penalty avoided if NO MORE THAN 63 DAYS pass without CREDITABLE COVERAGE following initial enrollment period.	penalty avoided if NO MORE THAN 63 DAYS pass without CREDITABLE COVERAGE following initial enrollment period.
Creditable Coverage	drug coverage from employer, union, Tricare,
Con-Creditable Coverage	drug coverage that, on average, is NOT expected to pay out as much as standard Medicare prescription drug coverage
Annua Enrollment Period (AEP)	Nov 15- Dec 31 which eligible individual can join or switch Medicare Advantage Plan (Part C) or Medicare Drug Plan (Part D) New Coverage begins on January 1st of the following year.
Open Enrollment Period (OEP)	period from Jan 1- Mar 31 in which Medicare beneficiary can enroll, disenroll from, or change a Medicare Advantage plan Changes are effecting the FOLLOWING MONTH Drug Coverage cannot be added or dropped during Open Enrollment
Approved Amount	maximum amount Medicare will pay a doctor or provider
Medicare Assignment	agreemement where patients "assigns" Medicare to pay his doctor/provider directly for services performed
Medicare Assignment	agreemement where patients "assigns" Medicare to pay his doctor/provider directly for services performed
If provider accept ASSIGNMENT they agree to:	only charge patient for dedutibles, coinsurance and copayments, accept Medicare's approved amount, submit claims to and be paid by Medicare
Medicare benefits CAN be assigned to an HMO OR PPO	Medicare benefits CAN be assigned to an HMO OR PPO
Participating Physician	ALWAYS accepts assignments
Non-Participating Physician	Can accept assignment on CASE-BY-CASE basis
Medicare claim is started when medical provider contacts (bills) Medicare	Medicare claim is started when medical provider contacts (bills) Medicare
Medical Summary Notice (MSN) AKA Explanation of Benefits	detailed notice sent to a Medicare recipient in the Original Medicare Plan after a doctor or provider files a claim for Part A or Part B services
Medicare recipient can appeal ANY claims decision	Medicare recipient can appeal ANY claims decision

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	Created by Det Ferraris over 11 years ago