Which health insurance program provides coverage for people over the age of 65 quizlet?

Medicare is part of the Social Security Act of 1965 and was signed into law by President Lyndon B. Johnson. Medicare is administered by the CMS (Centers for Medicaid Services). The SSA (Social Security Administration) enrolls individuals in Medicare and processes premium payments.

Medicare is funded in part by FICA payroll taxes. The tax is 2.9%: the employer pays 1.45% and the employee pays 1.45%. Self-employed individuals must pay the entire 2.9% tax. Beginning in 2013 an additional tax, called the unearned income Medicare contribution tax, will be levied against individuals with higher incomes. The additional tax is 3.8%.

Private organizations are contracted by the CMS to process claims payments, enroll medical providers, and investigate fraud. These companies function as intermediaries, or middlemen, between Medicare and the medical providers. Patients enrolled under Medicare cannot receive payment directly from Medicare. Medicare is set up to pay healthcare providers, not patients.

When Medicare was first introduced, it was composed of hospital and medical coverage (only Parts A and B), known as "Original Medicare." Since then, it has expanded to offer managed care and prescription drug coverage.

Medicare Part A provides coverage for inpatient hospital stays. Inpatient stays are those in which an individual must receive care or treatment in a hospital. Covered inpatient expenses include: semi-private room, meals, hospital services and supplies, drugs received during inpatient care, and general nursing services. Up to a maximum of 190 lifetime days are allotted for psychiatric hospital care. Use of a television or telephone, a private room unless medically necessary, and personal care items, such as toothbrush and toothpaste, are excluded from Part A coverage. Physician's fees and services received while an inpatient are covered by Part B.

Following is a breakdown of Part A hospital coverage, and the cost-sharing amounts that must be paid by the enrolled individual:

-During days 1-60 of each benefit period, a deductible of $1,216 in 2014 must be paid. All approved charges are paid by Medicare after the deductible has been met.

A benefit period begins on the day an individual enters the hospital or a skilled nursing facility (SNF), and ends when care has ceased for 60 consecutive days. An individual will begin a new benefit period if hospitalization or admission to an SNF occurs after a benefit period ends.

-During days 61 through 90 of a benefit period, daily coinsurance of $304 in 2014 must be paid. All approved charges are paid by Medicare after the daily coinsurance has been paid.

-If an individual is in the hospital beyond 90 days, he will begin to use lifetime reserve days. Each person has a maximum of 60 lifetime reserve days which can be used at any time after 90 days of inpatient care. The daily coinsurance for using lifetime reserve days is $608 in 2014. Medicare will cover all remaining covered charges. Lifetime reserve days are nonrenewable.

-After all lifetime reserve days have been used (after 150 days in the hospital), the individual is responsible for paying all hospital costs out-of-pocket.

Medicare Part A provides coverage for skilled nursing facilities (SNF) care after a three-day inpatient hospital stay for an illness or injury requiring SNF care. Covered SNF expenses include: semi-private room, meals, skilled nursing services, and rehabilitation. An individual's physician must declare that skilled care, such as physical therapy, is necessary in order for Medicare to cover SNF care. Medicare Part A does not cover custodial or long-term care. Following is a breakdown of Part A SNF coverage, and the cost-sharing amounts that must be paid by the enrolled individual:

-During the first 20 days of a benefit period, Medicare pays for all approved charges.

-During days 21 through 100 of a benefit period, the individual must pay coinsurance of $152per day in 2014, and Medicare will pay all remaining approved charges.

-After 100 days in an SNF, the individual is responsible for paying all costs.

Coverage will begin on the first day of the birthday month for an individual who enrolls during the first three months of the initial enrollment period. If the individual's birthday is on the first day of the month, coverage will being on the first day of the month prior. A person who enrolls in Part B during the month of his 65th birthday or during the last 3 months of the initial enrollment period will have a delayed coverage start date, depending on the month of enrollment.

Example: A person whose 65th birthday is in July, and enrolls in July will have a coverage start date of August 1st. If enrollment is delayed until August, coverage will begin October 1st.

If enrollment is delayed until September, coverage will begin December 1st. The only way to avoid the delayed coverage start date for Part B is to enroll during the first three months prior to the month of his 65th birthday.

An individual who is receiving Social Security or RRB benefits will be automatically enrolled in Part B upon Part A eligibility (unless the individual declines coverage) on the first day of the month of his 65th birthday.

A person who has Part A coverage and TRICARE must have Part B coverage in order to keep his/her TRICARE coverage. However, enrollment in Part B is not necessary to maintain TRICARE coverage if the service member is on active duty. Prior to the active duty member's retirement, enrollment in Part B must occur to maintain TRICARE coverage without interruption. Finally, enrollment in Part B may occur during the special enrollment period if a person has Medicare because he is age 65 or older, or disabled.

Individuals who are under the age of 65 and have a disability will be automatically enrolled in Part B if they are receiving Social Security or RRB disability benefits. Part B coverage begins on the 25th month of disability.

Individuals with Lou Gehrig's disease are automatically enrolled in Part B in the month that disability benefits commence. Individuals with ESRD can sign up to receive Part B coverage when they sign up for Part A.

Individuals who are not receiving Social Security or RRB benefits (those who are not eligible for premium-free Part A coverage) can sign up for Part B during their initial enrollment period, the three months prior to their 65th birthday until three months after their 65th birthday.

Individuals who do not sign up for Part B coverage upon initial eligibility, or later decide they want to enroll after declining Part B coverage (because they are employed and have primary coverage through their employer, or are under age 65 and have ESRD) can enroll during the general enrollment period. Coverage begins July 1st. If enrollment is delayed beyond the initial enrollment period, the premium will increase by 10% for every 12 months that enrollment is postponed, unless the individual is eligible to enroll during the special enrollment period. A person who was employed and delayed Part B enrollment, may, upon cessation of employment, enroll during the special enrollment period. In order to avoid any late enrollment penalties in the form of premium increases, an individual who continued to work beyond 65 can obtain a certificate of insurance from creditable group coverage from his or her employer when he retires and Medicare will waive the penalties for late enrollment.

Individuals with Part B coverage are responsible for paying an annual deductible of $147 in 2014 and 20% of all covered charges. Medicare pays the remaining 80% of covered charges after the deductible is met. Part B covers medically necessary services. Medicare beneficiaries pay nothing for most preventive services received by a doctor who accepts assignment. In some cases, a coinsurance may apply.

Part B covers outpatient hospital services received in a hospital, emergency room, or outpatient clinic. Part B also covers part-time services for limited home health visits, including 100% of approved charges and 80% of approved charges for durable medical equipment. Only drugs given at the doctor's office or hospital are covered by Part B.

Part B coverage for mental health services is limited to a benefit of 45% of approved charges. Medicare pays 100% of the cost of clinical laboratory services, such as blood tests and urinalysis. The blood deductible applies if not already met for Part A. For home health services, Medicare beneficiaries pay nothing for Medicare-approved services. A 20% coinsurance applies for durable medical equipment. For doctor services, the 20% coinsurance of the Medicare-approved amount applies.

For diabetes, coverage is provided for blood sugar testing monitors, blood test strips, lancets, blood sugar control solutions, and sometimes therapeutic shoes. Insulin is only covered if an external insulin pump is used. The 20% coinsurance and Part B deductible applies.

Flu shots are covered once every year during the flu season (fall or winter). The Medicare beneficiary pays nothing if the health care provider accepts assignment.

Mammograms are covered once every 12 months for women age 40 and older. If the doctor accepts assignment, the Medicare beneficiary pays nothing. Medicare covers prostate cancer screenings (digital rectal exam and PSA test - prostate specific antigen test) once every 12 months for men age 50 and older. The earliest the test may be received is the day after the 50th birthday. The 20% coinsurance and Part D deductible applies.

Medicare covers two types of physical exams:

A one-time "Welcome to Medicare" physical exam, as long as the physical exam is within the first 12 months of the Part B coverage effective date;
After that, Medicare covers one physical exam called the "yearly wellness visit," every 12 months. If the doctor accepts assignment, the Medicare beneficiary pays nothing.
Smoking cessation, or counseling to quit smoking, is covered as a preventive service, as long as the Medicare beneficiary has not been diagnosed with an illness caused or complicated by tobacco use. This is 100% covered by Medicare. The Medicare beneficiary pays nothing.

-Outpatient doctor and nursing services,
-Doctor visits,
-Physical examinations,
-Physical therapy,
-Preventative care,
-Surgery services,
-Diagnostic tests,
-X-rays,
-Supplies provided in an emergency room, doctor's office, clinic, or hospital, and
-Durable medical equipment at home.

Part B coverage does not include private duty nursing services, long-term care, intermediate skilled nursing and custodial care, skilled nursing home care after 100 days, physician charges that are greater than the amount approved by Medicare (> 80%), cosmetic surgery, routine physical exams except for the one-time physical exam, and the first three pints of blood. Part B does not cover dental care, eye care, routine foot care, hearing care, insulin, care received outside the United States, acupuncture, chiropractic care, cosmetic surgery, and outpatient prescription drugs.

Medicare Part C is also referred to as Medicare Advantage, and was formerly called Medicare+Choice prior to the Medicare Modernization Act of 2003. Part C is a managed care plan, offered by Medicare-approved private insurers. Part C encompasses the coverages of Parts A and B, and some plans offer coverage for prescription drugs, eye care, and dental care at an additional cost. The cost of medical services varies depending on the plan.

Part C plans may be offered as a Private Fee-For-Service, PPO, HMO, MSA, SNP, POS, or PSO plan. A SNP, or Special Needs Plan, is intended for individuals who are insured under Medicare and Medicaid. A PSO, or Provider Sponsored Organization, is managed by one or more medical providers. Medical services are received from the plan's provider(s).

Plan costs vary from plan to plan. However, the following schedule of coinsurance and deductibles applies to all Part D plans:

A deductible of $310 in 2014 must be paid by the individual before the plan begins to pay. For each month an individual has Part D coverage, a monthly premium is due. The monthly premium varies from plan to plan, but the national premium base average in 2014 is $32.42.
People with higher incomes may pay higher Part D monthly premiums.

After the individual has paid the first $310, the plan pays 75% of covered prescription drug costs, and the individual pays a copayment until the total paid by the plan and the individual (including the deductible) reaches a limit of $2,850.
Once the combined spending between the individual (including the deductible) and the plan reaches $2,850 the individual is in his coverage gap, known as the "doughnut hole", where he pays 72% of generic prescription drug costs and 52.5% of brand-name drug costs. The individual is in the coverage gap until he has spent $4,550 out-of-pocket over the course of the year.
After the individual has spent $4,550 out-of-pocket over the course of the year, the plan pays "catastrophic coverage", which includes all covered prescription drug costs except for a small copayment of about $6.35 for brand name prescription drug purchases, and $2.55 for generic.

To qualify for extra help, an individual must meet the following requirements:

-Have Medicare Part A and/or Part B
-Have lived in one of the 50 states or the District of Columbia
-Have combined savings, investments, and real estate are not worth more than $26,860, if married and living with a spouse, or $13,440 if not currently married or not living with a spouse. (homestead, car, and life insurance policies are not included in this amount)
-Have an annual income limited to $17,595 for an individual or $23,595 for a married couple living together.

In order to qualify for Medicaid nursing home and home health care benefits, an applicant must first pass the means tests, which verifies that the applicant has limited income and assets, and cannot afford the cost of his medical expenses. The applicant must also be disabled, blind, or over the age of 65. Some assets are not included in the asset limitation tests such as the applicant's primary residence, one vehicle, and wedding ring. Applicants must also be United States citizens and require nursing home care.

Individuals who qualify for public assistance are those with dependent children or who are blind, disabled or pregnant. Medicaid pays for medical care that certain financially needy individuals cannot afford, such as physician's fees, hospitalization, pregnancy and maternity care.

Medicaid provides coverage for: physician and skilled home nursing services, inpatient and outpatient hospital care, laboratory and x-ray services, home and rural health care services, screenings and treatment, family planning services, prescription drugs, dental services, private duty nursing services, eyeglasses, and medical supplies.

To be eligible for Medicare Savings Programs, a beneficiary must have Medicare Part A and have monthly income and resources below the listed amounts.

Monthly Income Limits:

QMB: $993/individual; $1331/married filing jointly
SLMB: $1187/individual; $1593/married filing jointly
QI: $1333/individual; $1790/married filing jointly
QDWI: $3975/individual; $5329/married filing jointly
Resource Limits:

QMB, SLMB, and QI: $7,160/individual; $10,750/married filing jointly
QDWI: $4,000/individual; $6,000/married filing jointly
Resources include money in checking and savings accounts, stocks and bonds. Resources exclude an individual's home, household items and furniture, vehicle, up to $1,500 for burial expenses, and burial plot.

Insureds must be incapable of performing some of the activities of daily living to receive LTC benefits. Activities of daily living, or ADLs, include bathing, dressing, eating, mobility, transferring, toileting, and continence. Most LTC policies specify that an insured must be unable to perform at least two ADLs, or be cognitively impaired. Policies also include age limits. Each policy is different, but many have a minimum age of 50 and maximum of 89 for purchasing a LTC policy. LTC policies cannot require the insured undergo a hospital visit prior to LTC nursing home coverage.