MEDICARE AND HUMANA| 472 QUESTIONS|
WITH COMPLETE ANSWERS
Monthly Premium (for people who pay a premium) Correct Answer: $407 each month
Late Enrollment Penalty Correct Answer: -If you don't buy it when you are 1st eligible your
monthly premium goes up 10% (you will have to pay the higher premium for twice the number
of years you could have had Part A but you didn't sign up).
-Enrollment January 1 to March 31 to enroll in Part B
-Coverage will start July 1 of that year.
Home Health Care Correct Answer: $0 home health care services
20% of the Medicare-approved amount for durable medical equipment.
Hospice Care Correct Answer: $0 for Hospice Care
-You may need to pay a co-payment of no more than $5 for each prescription drug and other
similar products form pain relief and symptom control while you are at home.
-In rare case it is not covered, Medicare Drug Plan could see if it is covered under Part D.
-You may need to pay 5% of the Medicare-Approved amount for inpatient respite care.
-Medicare doesn't cover room and board when you get hospice care in your home or another
facility where you live (like a nursing home).
Hospital In-patient Stay Correct Answer: $1,260 deductible for each benefit period.
-Days 1 -60 $0 coinsurance for each benefit period.
-Days 61 -90 $315 coinsurance per day of each benefit period.
-Days 91 and beyond $630 coinsurance per each "lifetime reserve day."
-After day 90 for each benefit period (up to 60 days over your lifetime).
-Beyond lifetime reserve days all costs.
Mental Health Policy Correct Answer: -$1,260 deductible for each benefit period.
-Days 1-60 $0 coinsurance per day of each benefit period.
-Days 61-90 $315 per each day (up to 60 days over lifetime.)
-Days 91 and beyond $630 coinsurance per "lifetime reserve day". After day 90 for each benefit
period (up to 60 days over your lifetime).
-Beyond lifetime reserve days: all costs.
-20% of the Medicare-approved amount for mental health services you get from doctors and
other providers while you are a hospital in-patient.
-*There's NO limit to the number of benefit periods you can have when you get mental healthy
care in general hospital. You can also have multiple benefit when you get care in a psychiatric
hospital.
-*Lifetime limit to 90 days*
Skilled Nursing Facility Stay Correct Answer: -Days 1-20 = $0 for each benefit period.
-Days 21-100 = $157.50 coinsurance per day of each benefit period.
-Days 101 and beyond = all costs.
,Medicare Part B (Medical Insurance) Correct Answer: Monthly Premium
-Most people pay the Part B premium $104.90 each month if you sign up when you are first
eligible.
However, if your modified adjusted gross income is reported on your IRS TAX RETURN from 2
years ago, is above a certain amount, you may pay more.
Medicare Part B costs if you have Original Medicare Correct Answer: *All Medicare Advantage
Plans must cover these services. If you are in a Medicare Advantage Plan, costs vary by plan and
may be either higher or lower than those in Original Medicare.
Medicare Part B Annual Deductible Correct Answer: -You pay $147 per year for your Part B
deductible.
Clinical Laboratory Services Correct Answer: -You pay $0 for Medicare-Approved Services
-20% of the Medicare-Approved amount for durable equipment.
Home Health Services Correct Answer: You pay $0 for Home Health Care Services
20% of the Medicare-Approved
Medical & other services Correct Answer: -You pay 20% of the Medicare-Approved amount for
most doctor services while you are a hospital in-patient), outpatient therapy and durable medical
equipment.
Outpatient Mental Health Services Correct Answer: -You pay nothing for yearly depression
screening if your doctor or health care provider accepts assignment.
20% of the Medicare-Approved amount for visits to a doctor or other health care provider to
diagnose or treat your condition. The Part B deductible applies.
-If you get your services in a hospital, outpatient clinic or hospital outpatient department, you
may have to pay an additional copayment or coinsurance amount to the hospital. This amount
will vary depending on the service provided, but will be between 20-40% of the Medicare-
Approved amount.
Partial Hospitalization Mental Health Services Correct Answer: -You pay a % percentage of the
Medicare-Approved amount for each service you get from a doctor or certain other qualified
mental health professionals. If your health care professional accepts assignment.
-You also pay coinsurance for each day of partial hospitalization services provided in a hospital
outpatient setting or community mental health center, and the Part B deductible applies.
Outpatient Hospital Services Correct Answer: -You generally pay 20% of the Medicare-
Approved amount for the doctor or other health care provider's services and the Part B deductible
applies.
-For all other services, you also generally pay a copayment for each service you get in an
outpatient hospital setting. You may pay more for services you get in a hospital outpatient setting
than you would pay for the same care in a doctor's office.
,-For some screenings and preventative services, coinsurance, copayments, and the Part B
deductible, don't apply. (so you pay nothing).
Medicare Part C (Medicare Advantage) Correct Answer: Monthly Premium
-The Part C monthly premium varies by plan.
-Deductibles, copayments & coinsurance, they also vary by plan.
Medicare Part D (Medicare Prescription Drug Coverage) Correct Answer: Monthly Premium
-The Part D monthly premium varies by plan (Higher income consumers may pay more).
-Late Enrollment Penalty = The cost of the late enrollment penalty depends on how long you
went without Part D or creditable prescription drug coverage.
-You may owe a late enrollment penalty if you go without Part D or creditable prescription drug
coverage for any continuous period of 63 days or m ore after your initial enrollment period is
over.
-In general, you'll have to pay this penalty for as long as you have a Medicare Drug Plan.
-Deductibles , copayments, & coinsurance. The amo9unt you pay for Part D deductibles,
copayments, and or coinsurance varies by plan.
MEDICARE PART A Correct Answer: -Hospital Care
-Skilled Nursing Facility Care
-Nursing Home Care (as long as custodial care you need).
-Hospice
-Home Health Services
Main Factors of Medicare Coverage Correct Answer: -Medicare coverage is based on 3 main
factores:
1. Federal and State Laws
2. National coverage decisions made by Medicare about whether something is covered.
3. Local coverage decisions made by companies in each state that process claims for Medicare.
These companies decide whether something is medically necessary and should in their area.
MEDICARE PART B Correct Answer: -Medicare Part B covers services (like lab tests,
surgeries, doctor visits, supplies, like wheelchairs and walkers) considered medically necessary
to treat a disease condition.
-Medicare Part B covers 2 types of services:
1. Medically necessary services or supplies that are needed to diagnose or treat your medical
condition and that meet accepted standards of medical practice.
2. Preventive Services = Health care to prevent illness (like the flu) or detect it at an early stage,
when treatment is most likely to work best.
*You pay nothing for most services if you get the services from a health care provider who
accepts assignment.
-Medicare Part B covers things like:
*Clinical Research
*Ambulance Services
*Durable Medical Equipment (DME)
*Mental Health
, >Inpatient
>Outpatient
>Partial Hospitalization
_Getting a second opinion before surgery.
-Limited outpatient prescription drugs.
How to find out if Medicare covers what you need? Correct Answer: -There are 2 ways to find
out if Medicare covers what you need:
1. Talk to your doctor or health care provider about why you need certain services.
2. Ask if Medicare will cover those services.
Medicare Drug Plans Coverage Correct Answer: -Each Medicare Prescription Drug Plan has its
own list of covered drugs (called a FORMULARY).
-Many drug plans place drugs into different 'tiers" on their formularies.
-Drugs in each tier have a different cost.
-A drug in a lower tier will cost you less than a drug in a higher tier.
-If your drug is in a higher tier and your prescriber thinks you need that drug instead of a similar
drug or a lower tier, you or your prescriber can ask your plan for an exception to get a lower
copayment.
How to find out about Prescription Drug coverage Correct Answer: -There are 2 ways to find
out about Prescription Drug coverage.
1. Medicare Prescription Drug Plan (Part D)
*Sometimes called (PDP), add coverage to Original Medicare. Some Medicare private fee-for-
service (PFFS) plans. Medicare Medical Savings Accounts (MSA) plans.
2. Medicare Advantage Plan (Part C)
*Like an HMO or PPO or other Medicare Health Plan that offers Medicare prescription drug
coverage, you get all of your Medicare Part A, Part B and prescription drug Part D through these
Plans.
Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PD's" .
*You must have PART A and PART B to join Medicare Advantage Plan.
Supplement and other Insurance Correct Answer: -If you have Medicare and other health
insurance or coverage, each type of coverage is called a "payer". When there is more than one
payer, "coordination of benefits" rules decide which one pays first.
-The "primary payer" pays what it owes on your bills first and then sends the rest to the
"secondary payer".
-In some cases, there may also be a "third payer".
What is a PRIMARY/SECONDARY PAYER? Correct Answer: -The insurance that pays first is
the "Primary Payer" and pays up to the limits of coverage.
-The one that pays second is the "Secondary Payer" and only pays if there are costs the primary
insurer didn't cover.
-The secondary payer (which may be Medicare) may NOT pay all of the uncovered costs.
_If your employer insurances is the secondary payer, you may need to enroll in Medicare Part B,
before your insurance will pay.
WITH COMPLETE ANSWERS
Monthly Premium (for people who pay a premium) Correct Answer: $407 each month
Late Enrollment Penalty Correct Answer: -If you don't buy it when you are 1st eligible your
monthly premium goes up 10% (you will have to pay the higher premium for twice the number
of years you could have had Part A but you didn't sign up).
-Enrollment January 1 to March 31 to enroll in Part B
-Coverage will start July 1 of that year.
Home Health Care Correct Answer: $0 home health care services
20% of the Medicare-approved amount for durable medical equipment.
Hospice Care Correct Answer: $0 for Hospice Care
-You may need to pay a co-payment of no more than $5 for each prescription drug and other
similar products form pain relief and symptom control while you are at home.
-In rare case it is not covered, Medicare Drug Plan could see if it is covered under Part D.
-You may need to pay 5% of the Medicare-Approved amount for inpatient respite care.
-Medicare doesn't cover room and board when you get hospice care in your home or another
facility where you live (like a nursing home).
Hospital In-patient Stay Correct Answer: $1,260 deductible for each benefit period.
-Days 1 -60 $0 coinsurance for each benefit period.
-Days 61 -90 $315 coinsurance per day of each benefit period.
-Days 91 and beyond $630 coinsurance per each "lifetime reserve day."
-After day 90 for each benefit period (up to 60 days over your lifetime).
-Beyond lifetime reserve days all costs.
Mental Health Policy Correct Answer: -$1,260 deductible for each benefit period.
-Days 1-60 $0 coinsurance per day of each benefit period.
-Days 61-90 $315 per each day (up to 60 days over lifetime.)
-Days 91 and beyond $630 coinsurance per "lifetime reserve day". After day 90 for each benefit
period (up to 60 days over your lifetime).
-Beyond lifetime reserve days: all costs.
-20% of the Medicare-approved amount for mental health services you get from doctors and
other providers while you are a hospital in-patient.
-*There's NO limit to the number of benefit periods you can have when you get mental healthy
care in general hospital. You can also have multiple benefit when you get care in a psychiatric
hospital.
-*Lifetime limit to 90 days*
Skilled Nursing Facility Stay Correct Answer: -Days 1-20 = $0 for each benefit period.
-Days 21-100 = $157.50 coinsurance per day of each benefit period.
-Days 101 and beyond = all costs.
,Medicare Part B (Medical Insurance) Correct Answer: Monthly Premium
-Most people pay the Part B premium $104.90 each month if you sign up when you are first
eligible.
However, if your modified adjusted gross income is reported on your IRS TAX RETURN from 2
years ago, is above a certain amount, you may pay more.
Medicare Part B costs if you have Original Medicare Correct Answer: *All Medicare Advantage
Plans must cover these services. If you are in a Medicare Advantage Plan, costs vary by plan and
may be either higher or lower than those in Original Medicare.
Medicare Part B Annual Deductible Correct Answer: -You pay $147 per year for your Part B
deductible.
Clinical Laboratory Services Correct Answer: -You pay $0 for Medicare-Approved Services
-20% of the Medicare-Approved amount for durable equipment.
Home Health Services Correct Answer: You pay $0 for Home Health Care Services
20% of the Medicare-Approved
Medical & other services Correct Answer: -You pay 20% of the Medicare-Approved amount for
most doctor services while you are a hospital in-patient), outpatient therapy and durable medical
equipment.
Outpatient Mental Health Services Correct Answer: -You pay nothing for yearly depression
screening if your doctor or health care provider accepts assignment.
20% of the Medicare-Approved amount for visits to a doctor or other health care provider to
diagnose or treat your condition. The Part B deductible applies.
-If you get your services in a hospital, outpatient clinic or hospital outpatient department, you
may have to pay an additional copayment or coinsurance amount to the hospital. This amount
will vary depending on the service provided, but will be between 20-40% of the Medicare-
Approved amount.
Partial Hospitalization Mental Health Services Correct Answer: -You pay a % percentage of the
Medicare-Approved amount for each service you get from a doctor or certain other qualified
mental health professionals. If your health care professional accepts assignment.
-You also pay coinsurance for each day of partial hospitalization services provided in a hospital
outpatient setting or community mental health center, and the Part B deductible applies.
Outpatient Hospital Services Correct Answer: -You generally pay 20% of the Medicare-
Approved amount for the doctor or other health care provider's services and the Part B deductible
applies.
-For all other services, you also generally pay a copayment for each service you get in an
outpatient hospital setting. You may pay more for services you get in a hospital outpatient setting
than you would pay for the same care in a doctor's office.
,-For some screenings and preventative services, coinsurance, copayments, and the Part B
deductible, don't apply. (so you pay nothing).
Medicare Part C (Medicare Advantage) Correct Answer: Monthly Premium
-The Part C monthly premium varies by plan.
-Deductibles, copayments & coinsurance, they also vary by plan.
Medicare Part D (Medicare Prescription Drug Coverage) Correct Answer: Monthly Premium
-The Part D monthly premium varies by plan (Higher income consumers may pay more).
-Late Enrollment Penalty = The cost of the late enrollment penalty depends on how long you
went without Part D or creditable prescription drug coverage.
-You may owe a late enrollment penalty if you go without Part D or creditable prescription drug
coverage for any continuous period of 63 days or m ore after your initial enrollment period is
over.
-In general, you'll have to pay this penalty for as long as you have a Medicare Drug Plan.
-Deductibles , copayments, & coinsurance. The amo9unt you pay for Part D deductibles,
copayments, and or coinsurance varies by plan.
MEDICARE PART A Correct Answer: -Hospital Care
-Skilled Nursing Facility Care
-Nursing Home Care (as long as custodial care you need).
-Hospice
-Home Health Services
Main Factors of Medicare Coverage Correct Answer: -Medicare coverage is based on 3 main
factores:
1. Federal and State Laws
2. National coverage decisions made by Medicare about whether something is covered.
3. Local coverage decisions made by companies in each state that process claims for Medicare.
These companies decide whether something is medically necessary and should in their area.
MEDICARE PART B Correct Answer: -Medicare Part B covers services (like lab tests,
surgeries, doctor visits, supplies, like wheelchairs and walkers) considered medically necessary
to treat a disease condition.
-Medicare Part B covers 2 types of services:
1. Medically necessary services or supplies that are needed to diagnose or treat your medical
condition and that meet accepted standards of medical practice.
2. Preventive Services = Health care to prevent illness (like the flu) or detect it at an early stage,
when treatment is most likely to work best.
*You pay nothing for most services if you get the services from a health care provider who
accepts assignment.
-Medicare Part B covers things like:
*Clinical Research
*Ambulance Services
*Durable Medical Equipment (DME)
*Mental Health
, >Inpatient
>Outpatient
>Partial Hospitalization
_Getting a second opinion before surgery.
-Limited outpatient prescription drugs.
How to find out if Medicare covers what you need? Correct Answer: -There are 2 ways to find
out if Medicare covers what you need:
1. Talk to your doctor or health care provider about why you need certain services.
2. Ask if Medicare will cover those services.
Medicare Drug Plans Coverage Correct Answer: -Each Medicare Prescription Drug Plan has its
own list of covered drugs (called a FORMULARY).
-Many drug plans place drugs into different 'tiers" on their formularies.
-Drugs in each tier have a different cost.
-A drug in a lower tier will cost you less than a drug in a higher tier.
-If your drug is in a higher tier and your prescriber thinks you need that drug instead of a similar
drug or a lower tier, you or your prescriber can ask your plan for an exception to get a lower
copayment.
How to find out about Prescription Drug coverage Correct Answer: -There are 2 ways to find
out about Prescription Drug coverage.
1. Medicare Prescription Drug Plan (Part D)
*Sometimes called (PDP), add coverage to Original Medicare. Some Medicare private fee-for-
service (PFFS) plans. Medicare Medical Savings Accounts (MSA) plans.
2. Medicare Advantage Plan (Part C)
*Like an HMO or PPO or other Medicare Health Plan that offers Medicare prescription drug
coverage, you get all of your Medicare Part A, Part B and prescription drug Part D through these
Plans.
Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PD's" .
*You must have PART A and PART B to join Medicare Advantage Plan.
Supplement and other Insurance Correct Answer: -If you have Medicare and other health
insurance or coverage, each type of coverage is called a "payer". When there is more than one
payer, "coordination of benefits" rules decide which one pays first.
-The "primary payer" pays what it owes on your bills first and then sends the rest to the
"secondary payer".
-In some cases, there may also be a "third payer".
What is a PRIMARY/SECONDARY PAYER? Correct Answer: -The insurance that pays first is
the "Primary Payer" and pays up to the limits of coverage.
-The one that pays second is the "Secondary Payer" and only pays if there are costs the primary
insurer didn't cover.
-The secondary payer (which may be Medicare) may NOT pay all of the uncovered costs.
_If your employer insurances is the secondary payer, you may need to enroll in Medicare Part B,
before your insurance will pay.
