Understanding Medicaid and Medicare Benefits

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Questions and Answers

Medicaid provides all of the following benefits EXCEPT

  • Doctor's services
  • Income assistance for work-related injury (correct)
  • Hospitalization
  • Prescription Drugs

Following an injury, a policyowner covered under Medicare Parts A & B was treated by her physician on an outpatient basis. How much of her doctor's bill will she be required to pay out-of-pocket?

20% of covered charges above the deductible

An applicant is discussing his options for Medicare supplement coverage with his agent. The applicant is 65 years old and has just enrolled in Medicare Part A and Part B. The insurance company is obligated to offer the supplement policy on a guaranteed issue basis.

True (A)

In which of the following situations would Social Security Disability benefits NOT cease?

<p>The individual's son gets a part time job to help support the family (B)</p> Signup and view all the answers

Social Security disability definition includes all of the following EXCEPT

<p>Disability expected to result in death (B)</p> Signup and view all the answers

If a person is disabled at age 27 and meets Social Security's definition of total disability, how many work credits must he/she have earned to receive benefits?

<p>12</p> Signup and view all the answers

Which of the following is NOT an enrollment period for Medicare Part A applicants?

<p>Automatic Enrollment (D)</p> Signup and view all the answers

Regarding Medicare SELECT policies, what are restricted network provisions?

<p>They condition the payment of benefits.</p> Signup and view all the answers

Which statement regarding qualifications for Social Security disability benefits is NOT true?

<p>The individual must be at least 65 years old (A)</p> Signup and view all the answers

An insured has Medicare Part D coverage. Upon reaching the initial benefit limit, what percentage of the prescription drug cost is the insured responsible for paying?

<p>25%</p> Signup and view all the answers

The primary eligibility requirement for Medicaid benefits is based upon

<p>Need</p> Signup and view all the answers

How long is an open enrollment period for Medicare supplement policies?

<p>6 months</p> Signup and view all the answers

In order for an insured under Medicare Part A to receive benefits for care in a skilled nursing facility, the insured must have first been hospitalized for 3 consecutive days.

<p>True (A)</p> Signup and view all the answers

To sign up for a Medicare prescription drug plan, individuals must first be enrolled in Medicare Part A.

<p>False (B)</p> Signup and view all the answers

Which of the following statements is NOT true concerning Medicaid?

<p>It consists of 3 parts hospitalization, doctors, services, disability income (A)</p> Signup and view all the answers

Which type of care is NOT covered by Medicare?

<p>Long Term Care (A)</p> Signup and view all the answers

Which of the following is NOT covered by Medicare?

<p>Cosmetic Surgery (C)</p> Signup and view all the answers

Which of the following is NOT a factor in determining qualifications for Social Security disability benefits?

<p>Worker's Occupation (B)</p> Signup and view all the answers

Which of the following is NOT covered under Plan A in Medigap insurance?

<p>The Medicare Part A deductible (D)</p> Signup and view all the answers

Concerning Medicare Part B, which statement is INCORRECT?

<p>It is fully funded by Social Security taxes (FICA) (D)</p> Signup and view all the answers

All of the following individuals may qualify for Medicare health insurance benefits EXCEPT

<p>A retired person age 50 (A)</p> Signup and view all the answers

For how many days of skilled nursing facility care will Medicare pay benefits?

<p>100</p> Signup and view all the answers

In which Medicare supplemental policies are the core benefits found?

<p>All plans (E)</p> Signup and view all the answers

Prior to purchasing a Medigap policy, a person must be enrolled in which of the following?

<p>Parts A and B of Medicare (D)</p> Signup and view all the answers

The part of Medicare that helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care, is known as

<p>Part A</p> Signup and view all the answers

Which of the following programs expands individual public assistance programs for people with insufficient income and resources?

<p>Medicaid</p> Signup and view all the answers

Which of the following is NOT covered under Part B of a Medicare policy?

<p>Routine dental care (A)</p> Signup and view all the answers

A Medicare supplement plan must have at least which of the following renewal provisions?

<p>Guaranteed renewable (B)</p> Signup and view all the answers

A 63 year old man is planning to be employed until age 68. When will he be eligible for Medicare?

<p>Age 65, regardless of employment status.</p> Signup and view all the answers

Which of the following statements is CORRECT concerning the relationship between Medicare and HMOs?

<p>HMOs may pay for services not covered by Medicare (D)</p> Signup and view all the answers

Once the person meets the stringent requirements for disability benefits under Social Security, how long is the waiting period before any benefits will be paid?

<p>5 months</p> Signup and view all the answers

An insured becomes disabled at age 22 and can no longer work. She meets the definition of total disability under Social Security. What other requirement must the insured have met to receive Social Security disability benefits?

<p>Have accumulated 6 work credits in the past 3 years (B)</p> Signup and view all the answers

A Medicare SELECT policy does all of the following EXCEPT

<p>Provide benefits for services provided by non-network providers (A)</p> Signup and view all the answers

Which type of Medicare policy requires insureds to use specific healthcare providers and hospitals (network providers), EXCEPT in emergency situations?

<p>Medicare SELECT (A)</p> Signup and view all the answers

All of the following are covered by Part A of Medicare EXCEPT

<p>Physician's and surgeon's services (E)</p> Signup and view all the answers

Which of the following statements is INCORRECT concerning Medicare Part B coverage?

<p>Part B coverage is provided free of charge when an individual turns age 65 (E)</p> Signup and view all the answers

Which of the following statements is NOT correct regarding Medicare?

<p>Medicare Advantage must be provided through HMOs (D)</p> Signup and view all the answers

Medicare Part A

<p>provides hospital care</p> Signup and view all the answers

Medicare Advantage (previously Medicare + Choice)

<p>offers expanded benefits for a fee through private health insurance programs such as HMOs and PPOs</p> Signup and view all the answers

How many pints of blood will be paid for by Medicare Supplement core benefits?

<p>First 3</p> Signup and view all the answers

All of the following statements about Medicare supplement insurance policies are correct EXCEPT

<p>They cover the cost of extended nursing home care (A)</p> Signup and view all the answers

All of the following qualify for Medicare Part A EXCEPT

<p>Anyone who is willing to pay a premium (B)</p> Signup and view all the answers

Following hospitalization because of an accident, Bill was confined in a skilled nursing facility. Medicare will pay full benefits in this facility for how many days?

<p>20</p> Signup and view all the answers

Medicare Part A services do NOT include which of the following

<p>Outpatient Hospital Treatment (C)</p> Signup and view all the answers

Hospice care is intended for

<p>the terminally ill</p> Signup and view all the answers

Which of the following statements concerning Medicare Part B is correct?

<p>It covers physician services, diagnostic tests, and physical therapy (E)</p> Signup and view all the answers

Which of the following is INCORRECT concerning Medicaid?

<p>It is solely a federally administered program (C)</p> Signup and view all the answers

Medicaid

<p>an assistance program for persons with insufficient income and/or resources to pay for health care. States administer the program that is financed by federal and state funds</p> Signup and view all the answers

Which of the following statements is CORRECT about Social Security?

<p>To be eligible, one must meet certain requirements (A)</p> Signup and view all the answers

Which of the following must be present in all Medicare supplement plans?

<p>Plan A (C)</p> Signup and view all the answers

All of the following are advantages of an HMO or PPO for a Medicare recipient EXCEPT

<p>Elective cosmetic procedures are covered (A)</p> Signup and view all the answers

All of the following statements about Medicare Part B are correct EXCEPT

<p>It is a compulsory program (A)</p> Signup and view all the answers

Flashcards

Medicare Supplement Guaranteed Issue

The applicant must be offered the supplement policy on a guaranteed issue basis, regardless of their health status.

Guaranteed Renewable

This means the policy will renew for life, and premiums can only be increased for all policyholders in the same class.

Medicare Parts A & B Eligibility

A person must be enrolled in Medicare Parts A and B before purchasing Medigap coverage.

Medicare Part A Coverage

Medicare Part A provides benefits for hospital care, skilled nursing facility care, hospice care, and home health care.

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Medicare Part B Coverage

Medicare Part B covers physician services, outpatient care, and preventive services.

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Medicare SELECT Network Providers

Medicare SELECT plans require insureds to use specific healthcare providers and hospitals (network providers), except in emergency situations.

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Medicare Part D Donut Hole

Medicare Part D, the prescription drug benefit, has a coverage gap known as the 'donut hole'.

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Medicaid Eligibility

Medicaid is a needs-based program, meaning eligibility depends on income and resources.

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Medicare Part B Elective Coverage

Medicare Part B is elective, meaning individuals can choose whether or not to enroll. However, a monthly premium is required for Part B.

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Medicaid Administration

Medicaid is a federally funded program administered by individual states, creating variations in program benefits and eligibility requirements.

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Medicare Part A Automatic Enrollment

Medicare Part A is automatic for those who are eligible, typically upon reaching age 65. It is financed through payroll taxes.

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Medicare Part B Funding

Medicare Part B is primarily financed by beneficiary premiums. It is not fully funded by Social Security taxes.

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Medicare Advantage (Part C)

Medicare Part C (Medicare Advantage) offers expanded benefits for a fee through private health insurance programs such as HMOs and PPOs.

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Social Security Disability Benefits

The Social Security Disability program has stringent requirements and a five-month waiting period before benefits begin.

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Medigap Supplemental Insurance

Medigap policies are supplemental to Medicare and help cover out-of-pocket expenses. There are various plans with different levels of coverage.

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Social Security Benefit Eligibility

Social Security benefits are based on the individual's work history and contributions. To be eligible, one must have earned a certain number of credits, typically at least 40.

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Medigap Plan A Coverage

Plan A of Medigap insurance covers the Medicare Part A deductible, but not the Part B deductible.

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Medicare Part A Coverage Overview

Medicare Part A covers inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care.

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Medicaid Funding and Administration

Medicaid is a state-administered program that is funded by both the federal government and individual states. This leads to variations in coverage and eligibility requirements across states.

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Medicare Supplement Core Benefits

Medicare Supplement plans must include the core benefits found in Plan A. These benefits include coverage for the Medicare Part A deductible, the first 3 pints of blood, and the Part A co-insurance.

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Guaranteed Renewable Feature

Medicare Supplement plans are guaranteed renewable, meaning the insurance company cannot cancel the policy, and the premiums can only be increased for all policyholders in the same class.

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Social Security Eligibility

Individuals who have worked and paid Social Security taxes are typically eligible for Social Security benefits upon reaching retirement age, often age 67.

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Medicare Part B Coverage Highlights

Medicare Part B covers physician services, outpatient care, and certain preventive services. However, it does not cover prescription drugs or routine dental care.

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Medicare Part A Skilled Nursing Coverage

Medicare Part A covers up to 100 days of skilled nursing facility care, but only if the patient has been hospitalized for at least 3 consecutive days prior to admission.

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Medicare Part B Premium

Medicare Part B requires a monthly premium, which is determined based on the beneficiary's income level.

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Medicare Advantage Benefits

Medicare Advantage plans offer a variety of benefits that may exceed the coverage offered by traditional Medicare, but they typically have a lower premium.

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Medicaid Program Overview

Medicaid is a needs-based program that provides health insurance to low-income individuals and families.

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Medicare Part A Hospital Insurance

Medicare Part A, also known as hospital insurance, covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care.

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Study Notes

Medicaid

  • Medicaid provides assistance for healthcare to individuals with limited income and resources.
  • While income assistance for work-related injuries is a benefit, this is not the complete list of Medicaid benefits.

Medicare Parts A & B

  • Outpatient treatment subject to 20% copay for covered charges above the deductible.

Medicare Supplement Coverage

  • Insurance companies must offer Medicare supplement policies on a guaranteed issue basis for those newly eligible for Part A & B (age 65).

Social Security Disability Benefits

  • Disability benefits do not stop if the recipient's child finds a part-time job.
  • Disability is not determined by expected duration; it's about the present inability to work.
  • 12 work credits are required for those under 65 to receive benefits.
  • Factors to qualify include work history, inability to work due to disability, and meeting eligibility criteria (not age-specific unless over 65).
  • A waiting period of 5 months exists before receiving disability benefits. The applicant must have earned at least 6 credits in the three years immediately before applying for the benefits.

Medicare Enrollment Periods

  • Medicare Part A applicants do not have an automatic enrollment period.

Medicare SELECT Policies

  • Payment for benefits may be conditioned due to participating in a restricted provider network.

Medicare Prescription Drug Plans (Part D)

  • The insured is responsible for 25% of the prescription drug cost once the initial benefit limit is reached.

Medicare Part A

  • Covers inpatient hospital care, skilled nursing facility care, home health care, and hospice care.
  • A three-day hospital stay requirement precedes skilled nursing facility care coverage.
  • It does not cover outpatient hospital treatment, which is covered under Part B.

Medicare Part B

  • Covers physicians' services, diagnostic tests, and physical therapy, but not routine dental care. It is not funded by Social Security taxes alone; premiums are paid. It is elective.

Medicare and HMOs

  • HMOs and PPOs may offer services beyond Medicare coverage.

Medicare Eligibility

  • Medicare eligibility is dependent on age 65 or other qualifying criteria. A retired person of age 50 does not qualify for Medicare benefits.

Medicare Payment for Skilled Nursing Facility Care

  • Medicare pays for up to 100 days of skilled nursing facility care following hospitalization for 3 days.
  • Requires prior hospitalization for 3 consecutive days.

Medicare Supplement Policies

  • All Medicare supplement plans cover the core benefits.
  • Medicare supplement plans must be guaranteed renewable.
  • These plans do not cover long-term care costs.
  • Before you can purchase a Medigap policy, you must be enrolled in Part A and Part B of Medicare.
  • The first 3 pints of blood are covered in a Medicare Supplement plan

Medicare Part A and Part B Enrollment

  • A person must be enrolled in Part A to enroll in Part D (Prescription Drug Coverage)

Medicare and Cosmetic Surgery

  • Cosmetic surgery is not covered under Medicare.

Social Security Disability Requirements

  • Employment occupation is not a factor in determining eligibility.

Medicare Part A Deductible

  • Medicare Part A deductible is not covered by Medigap plans.

Medicare and Blood Transfusions

  • First 3 pints of blood are covered in a Medicare Supplement plan.

Medicare and Benefit Limits

  • Initial benefit limit, 25% coverage after is reached.

Hospice Care for Terminally Ill

  • Hospice care is intended for those with a projected short lifespan as determined by certain medical criteria.

Medicare and Physician Services

  • Medicare Part B covers the costs of physician and surgeon's services.

Medicaid Administration

  • Multiple stakeholders are involved in Medicaid program administration (federal and state).

Medicare Advantage

  • Offers expanded benefits (compared to standard Medicare) within private insurance frameworks via HMOs or PPOs, for a premium.

Social Security Eligibility

  • Eligibility is dependent on meeting specific requirements.

Medicare and HMO or PPO Advantages

  • Cosmetic elective procedures are not covered by Medicare Advantage plans.

Medicare Part B Requirements

  • Part B is not compulsory. Individuals may elect to enroll and pay a premium.

Medicare Part A Hospital Care

  • Medicare Part A provides coverage for hospital care, hospice, and skilled nursing facilities

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