UHC Exam 1: Medicare/Medicaid Exam Study Verified Answers.

Medicare - correct answer established based on the need of health insurance for the elderly; was added as an Amendment to the Social Security Act (Title XVIII) Medicare Eligibilities - correct answer Requires that individuals have worked at least 10 years in Medicare-covered employment or have paid taxes into the Medicare system, are US Citizens or permanent residents, and are at least 65 years old. People under 65 may qualify for Medicare if they have End-Stage Renal Disease and require dialysis or a kidney transplat or if they recieve Social Security disability benefits (and have been for at least 24 months) Medicare Enrollment and Spending - correct answer Enrollment: 57 Million Spending: $680 Billion Medicare: Part A - correct answer Hospital Insurance: Covers in-patient hospital care and other types of institutional care Medicare Part A Benefit Period - correct answer A deductible of $1316 is paid at the beginning of each period, which begins when a person enters the hospital and ends when a person has not been a patient in a hospital or skilled nursing facility for 60 consequtive days (90 day periods total) 60 day lifetime reserve days are available once the 90 days of the benefit period have been used 190 day lifetime supply of inpatient psychiatric care is separate from the benefit periods and reserve days Individual also receives 100 days per benefit period at a skilled nursing facility care for short-term skilled care (not custodial care - should be care only provided in nursing homes) that can only be used if preceded by a hospital stay of at least 3 days Hospice care (for patients with a life expectancy of less than 6 months that have waived the right to traditional treatment) is offered with very little patient cost-sharing (Pay 5% of Rx Drugs, repite care, grief counseling) Medicare is not applicable if traveling outside of the US Funding comes from payroll taxes from employees and employers Medicare Part B - correct answer Supplementary Medical Insurance (SMI) Includes physician services, a variety of outpatient services, home health care, drugs that are not self-administered, and a variety of preventative services Everyone eligible/receiving Part A can choose to purchase Part B; a 10% penalty on the premium is applied every year Part B is not purchased by an eligible individual Everyone on Part B is charged a monthly premium that is automatically taken out of their social security check Part B Cost Sharing - correct answer Includes annual deductible of $183 plus 20% of approved charges (what Medicare is willing to pay) Assignment: provider's charge equals Medicare;s approved charge (whatever Medicare says the charge will be) Balance Billing: patient pays the difference between actual and approved charge if the physician does not agree to the assignment (can be limited by federal government) Medicare Participating Provider: accepts assignments for all Medicare services Funding comes from the general revenue of federal government Medicare Part C - correct answer Medicare Advantage Encourages Medicare patients to enroll in managed care organizations (private insurance companies); patients still pay Part B with a potential added premium being charged Medicare Part D - correct answer Prescription Drug Benefit Prescription drug plan (PDP); may or may not be covered as part of Part C Income-based additional premium that is directly deducted from a Social Security check Standard Design includes a deductible ($400 paid out of pocket), then 25% coinsurance until a certain level of drug cost is reached, at what point a coverage gap would occur, where the individual would have no coverage; on the other side of the coverage gap (once a certain amount had been paid out of pocket) is catastrophic coverage (patient pays for 5% of costs) Cost Containment Tools of Part D - correct answer Formularies (which drugs are covered: 6 categories of drugs that must be covered, with other categories requiring only 2 drugs per category being covered and some not being covered at all), Tiered Cost Sharing, Prior authorization, Step Therapy, Restricted Networks (indicates which pharmacists cannot be used under certain insurance plans) Need for Supplemental Insurance under Medicare - correct answer Retiree health insurance through employer/union, Medicaid (if poor enough), Managed care via Medicare Advantage plan through Part C, Medicare supplement insurance poly (Medigap) (10 separate, supplemental policies available for purchase A-N, each letter added is an added benefit to the plan)