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Social Insurance
Benefit Period
Enrollee - a person enrolled with the…
Social Insurance
- Benefit Period
- Enrollee - a person enrolled with the benefit.
- Social Security Disability - Insured Status - fully or currently insured - depending on the number of coverage credits earned.
- Wwaiting Period - to receive the benefit.
Medicare
- Federal program
- Age 65 or older
- Recent green card or newimmigrants don’t qualify.
- Those can still purchase if living in US for 5 years.
- Administered by CMS - center of Medicaid service, division of Department of Heath andHuman Services.
- Part A - Hospital Insurance - financed through a portion of the payroll tax (FICA).
- PART B - Medical Insurance - Financed bimonthly premiums and general revenuesof the federal government.
- Part C - Medicare Advantage - health care services thought all availableprovider organizations.
- Part D - Prescription Drugs
- Actual charge - how much a physician or supplier charge for particular service.
- Ambulatory Surgical Services - not hospital stay.
- Approved Amount - reasonable amount that part B covers.
- Assignment - Doctor accepts the Medicare approved amount as full payment for the covered services.
- Carriers - process claims that are submitted by doctorsand suppliers under Medicare.
- Comprehensive Outpatient Rehabilitation Facility.
- Excess charge -Difference from what Medicare
covers and the actual charge.
- Limiting charge - maximum amount a physician may charge.
- Pap Smear screening - once every 2 year included.
- buy
Enrollment Periods
- IEP - Initial enrollment period = 7 oaths to enroll = 3 months before turning 65 and 3 months after the birthday month. If not, needs to pay late enrollment payment.
- General enrollment period = annual enrollment period - for theones who didn’t enroll in the designated period and now needs to pay 10% extra for part B = Jan 1st to march 31st.
- Open enrollment of 6 months for Medigap = Medicare supplement - after enrolled to part B.
- SEP - Special enrollment period - who waited to enroll because of group heath plan. - max 8 months after termination.
Part A
- Hospitalcare, Nursing facility care, home care and hospice.(last two after being in the hospital for 3days)
- Elegibility younger than 65 but entitled to social security disability for 24 months.
Does not have record but uses the spouse record that is at least 62.
Has end stage renal disease ESRD = dialysis or transplant.
Has ALS = sclerosis’s
- Premium free = 40 quarters = 10 years of work.
$471 premium = 30 quarters and 31 to 39 quarters = $259
Inpatient Hospital care
- Up to 90 days in a participating hospital subject to deductible.
- 60 days full and 30 days copay.
- semi-privet room, meals, anesthesia, nursing, operating and recovery room, intensive and coronary care, drugs, lab tests,X-rays, rehabilitation, blood and preparatory for kidney transplant.
- Not include first 3 pints, and psychiatric facility for 190 for life.
Skilled Nursing Facility Care.
- 100 days in each benefit period.
- Doctor must certify that daily skilled is necessary.
Home Heath Care
- Health visits unlimited to nursing care,physical therapy and speech therapy, part time aides, occupational therapy and medical social services and equipment.
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Part B
- Pays for Doctor and Medical services that are not coveredby hospital insurance.
- Funded by General Revenues from Federal Government.
- Permanent Kidney failure covered.
- Standard Monthly Premium until certain amount of gross income.
- you can decline and enroll later on.
Doctor Services
- Any location in the us territory.
- Surgical, diagnostic tests, X-rays and nursing.
Outipatient Hospital Services
- basically covers also clinic
HomeHealth Visits
- Limits of days and hours per day of care.
- Excedent will be covered by Medicaid.
Other Medical Services
- ambulance, transportation, home dialysis, periodic support, independent laboratories tests, oral surgery, physical therapy, X-rays and radiation treatments.
Prescription to Drugs (limited coverage)
- Only drugs that are admisnistered in a hospital outpatient department.
- Injected in a doctor’s office.
- Oral cancer, durable equipment (nebulizem or infusion)
- Other than that 100% not covered. Except cover part D.
Outpatient treatment of Mental Illenss
- Depression or anxiety
- Outpatient hospital department.
- 20% co insurance.
- Not covered in part A
Yearly wellness visit
- Welcome to Medicare free preventive visit during the 12 first months;
- Additional tests or services during the same visit will be charged.
What Part B does not cover.
- Private duty nursing
- Skilled nursing care cost over 100 days.
- Intermediate nursing home care.
- Physician charges above Medicare’s.
- most patient prescription drugs
- Care outside the country.
- Custidial care received at home.
- Dental not accidental
- Act of war
Part C
- ACT 2003 changed the name to Medicare Advantage.
- Low out of pocket costs than original Medicare but not all benefits like hospice care.
- Must be enrolled in part A and B.
- Provided by an HMO approved or PPO.
- Everything almost is covered so no forms or admin required.
- Not prescriptions, eye exams, hearing aids and dental care.
- Private Fee for Service Plan - offered by private companies supported by Medicare\gorvenment.
- Special Needs Plans - Reside in nursing home or chronic medical conditions.
Part D
- Prescription Drugs through PDPs (Private Prescption Drug Plans).
- Need to be enrolled in part A and B.
- 1% penalty for late enrollment.
- $4130 = 25% off for being generic, 25% covered by the plan.
- $6550 enters in the catastrophic coverage so the copay is 5% only.
Exclusions
- Acupunture
- Deductibles for other heath care private services.
- Dental care and dentures
- Chiropratic
- Cosmetic surgery.
- Custodial care.
- Heath care outside from US.
- Hearing aids and exams
- Orthopedic shoes.
- Routine eye care and eyeglasses (except after cartaract surgery).
- Immunizations - expect flu and pneumonia.
- Private duty nursing.
MEDIGAP — Medicare Suplement Policies
- Cover Deductibles and copayment from Medicare.
- Not administered federally.
- Sold and serviced by private insurers and HMO’s
- Omnibus Budget Reconciliation Act. - OBRA
NAIC to develop a standardized model for Medicare Supplement policies and avoid federal fraud.
- 6 months after signing up for Medicare Part B. So that’s also the need for Part A.
- Cover all the preexisting conditions arise of more than 6 months from the effective date of coverage.
- Not charge more because of past or present heath problems.
- Guaranteed Renewable
- 30 days free look.
- Premiums can greatly vary.
- Buyers Guide needs to be presented at the time of application.
- Once applicant eligible, covered must be offered on guaranteed issue basis.
- Insurance Comissioner or director needs to approve advertisements of it.
- Buyers guide need to be showed at application time.
Part A
Coinsurance/Copayment - Not Deductible
Additional hospital costs for more 365 days where Medicare stops.
Hospice care coinsurance.
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Medicaid
- Federal and state funded
- Administered by the states Department of Public Welfare
- Low income FPL (federal poverty level) + age 65 or blindness or pregnancy or caring for children receiving welfare benefits.
-AffordableCare Act - Verification of through Social Security Adm. And Department of Homeland Security instead of document anti on provided.
-Each state has their own plan to verify.
Services Provided
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Periodic screening, diagnosis, and treatment;
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Medicaid also pays for prescription drugs, dental services, private duty nursing services, eyeglasses, check-ups, and medical supplies and equipment.
Social Security Benefits
- Disability income benefits
- Also called as old age or survivors.
- Disability determination Service services - DDS
- More than 12 months.
- Waiting period of 5 months .
- Primary insurance amount - PIA
- PAYS 57% Average.