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135 Cards in this Set
- Front
- Back
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The outline of coverage for Medicare supplement policies is |
A summary of the policy applied for or issued.
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No long-term care policy can pay a cash surrender value unless |
The dividends or refunds are applied as a reduction of future premiums or an increase in benefits. |
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What is the maximum amount that can be contributed to an MSA of the high-deductible plan for individuals? |
65% |
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In long-term care (LTC) policies, as the benefit period lengthens, the premium |
Increases. |
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An insurance agent replaces a long-term care policy for his client. The benefits of the replacement policy are substantially greater than the benefits of the replaced policy. The agent’s first-year commission is 40%. His renewal commission is 4%. What commission rate will the agent be paid on scale? |
40% |
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An optional long-term care insurance benefit that provides a reduced paid-up benefit amount is the |
Nonforfeiture benefit. |
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Regarding long-term care coverage, as the elimination period gets shorter, the premium |
Gets higher. |
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A man has just completed an inpatient hospital stay of 100 consecutive days. How many lifetime reserve days has he used? |
10 |
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Doctors and hospitals who join a Medicare HMO are called the plan's |
Network. |
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Every insurer providing long-term care insurance in North Carolina is required to issue a Shopper's Guide |
Before sale |
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Medicare may pay for ambulance transportation to: |
a nearest medical facility. |
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Immunosuppressive drugs are |
Needed for life |
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An insured receives health care through both Medicare and Medicaid. She currently has prescription drug coverage through Medicaid. Does the insured need to enroll in Medicare Part D? |
Yes, she must begin receiving her prescription drug coverage through Part D. |
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When does enrollment begin for a person that becomes age 65. |
Enrollment begins on the first day of the month in which the person becomes age 65. |
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Medicare Part B is financed by |
Copayments, deductibles, a monthly premium and a government subsidy. |
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What would a physician utilize if he/she wanted to know if a treatment is covered under an insured's plan and at what rate it will be paid? |
Prospective Review |
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What is the Medicare Part A deductible? |
$1288 |
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What are the set deductibles and copayments for inpatient hospitalization? |
1-60 Days = $1288 61-90 Days = $322 91-150 Days = $644 150 + Days = $0 |
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What is the penalty for individuals who drop out of Medicare Part B and then re-enroll? |
The premium will be increased by 10% for each full 12 months the individual could have been enrolled, but was not. |
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First-Dollar Coverage |
A term applied to medical expense policies that pay covered expenses from the first dollar up to the specified limits, without the use of deductibles or waiting periods. Applies to Home Health Care. |
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How many days is Skilled Nursing Facility Coverage paid at no cost to insured? |
20 days |
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How much is the Medicare Part B deductible? |
$166 |
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Day 21-100 for skilled nursing care what will the patient pay daily? |
$161 |
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How long are the benefit periods in Medicare Part A? |
A benefit period begins the first day an individual receives a Medicare covered service in a qualified hospital, and ends when the individual has been out of a hospital for 60 days in a row. |
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The benefit period for the Medicare Part B deductible is |
1 year |
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Rural health services exclude coverage for: |
durable medical equipment, ambulance services, prosthetic devices, speech and occupational therapy providers |
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Medical Savings Account (MSA) characteristics: |
*Available to groups of 50 or fewer employees *The employee can use the funds to cover health insurance deductibles during the year *It is an employer-funded account linked to a high-deductible medical insurance plan *If there is a balance at the end of the year, the employee can allow it to earn interest or withdraw |
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What is a Private Fee-For-Service (PFFS) plan? |
A Medicare-approved private insurance plan in which Medicare pays the plan premium for Medicare-covered services and the plan provides all Medicare benefits. |
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Prior to obtaining coverage through Medicare Part D, individuals must have which of the following coverages? |
Medicare Part A or B |
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What is the Medicare Part D deductible? |
$360 |
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Those who enroll in the standard prescription drug benefit plan may pay a monthly national base premium of: |
$34.10 |
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Pre-existing Condition Policy for Medigap |
The insurer can refuse to cover a health problem that was diagnosed or treated during the 6 months before the policy issue date, for a specified amount of time. |
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Discontinuance |
The sale or transfer of a Medicare Supplement business to another issuer |
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What are the disabled insured's options for the purchase of a Medigap policy? |
The insured can purchase A, C, or F |
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What is Omnibus Budget Reconciliation Act (OBRA) or 1990? |
Medicare Supplement insurance may not be denied on the basis of an applicant's health status, claims experience, or medical condition during the first 6 months after a Medicare beneficiary age 65 or older first enrolls in Part B of Medicare. |
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Medigap Plan C includes: |
-Basic benefits -Skilled nursing coinsurance -Medicare Part A deductible -Medicare Part B deductible -Foreign Travel Emergency |
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Medigap Plan A includes: |
Covers only core or basic benefits and the first 3 pints of blood |
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According to NC Law, the person who seeks to contract for a Medigap Insurance policy is known as: |
The applicant |
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To be eligible for Medicare Supplement policy a person must be: |
Age 65 and have Medicare Part A and B |
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When one spouse is in a nursing home and receiving Medicaid services, the community spouse is allowed to keep how much of he couple's assets? |
50% of the couple assets, with set minimum and maximum amounts |
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Which of the following options allows states to extend Medicaid eligibility to additional persons? |
Medically needy persons (MN), an option that allows states to extend Medicaid eligibility to additional persons. |
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What is the Qualified Medicare Beneficiary (QMB) program? |
Helps pay Medicare premiums, deductibles, and coinsurance for Medicare eligible beneficiaries. |
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What does "community spouse" mean? |
The spouse of an institutionalized individual who remains at home. |
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According to NC asset rules for Medicaid insured, the look-back period for assets transferred to an individual is: |
5 years (60 months) |
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Services which enable an individual to remain at home who would otherwise be institutionalized are called the |
Community Alternatives Program |
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What does Qualified Medicare Beneficiaries (QMBs) mean? |
Those Medicare beneficiaries who have resources at or below twice the standard allowed under the Supplemental Security Income program, and incomes at or below 100% of the Federal Poverty Line. |
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A patient eligible for Medicaid is entering a nursing facility. How will his and his spouse's assets and resources be counted? |
All their resources will be combined. The countable resources of the couple are combined to determine eligibility for Medicaid. |
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Special Low-Income Medicare Beneficiary (SLMB) |
A program that pays Medicare Part B premiums for person entitled to Medicare Part A and whose income are slightly higher (up to 20% higher) than the federal poverty level. These beneficiaries are still responsible for their own Medicare deductibles, coinsurance and other charges. |
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What is Long-term care insurance |
Any contract of insurance offering institutional and non-institutional support to restore deteriorating health and to maintain functional independence. |
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In North Carolina, the expected loss ratio for individual long-term care insurance is at least: |
60% for individual policies; 75% for group policies |
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What is Waiver of Premium? |
An insured has a long-term care policy that includes a rider that states that should the insured be in a nursing home for 90 consecutive days, he can stop his premium payment. |
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The outline of coverage must include: |
-Describe policy provisions -Coverages -Limitations It cannot contain material of an advertising nature. |
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An insured has cancer. She has been offered a long-term care policy that a waiver limiting and reducing long-term care benefits related to treatment of cancer. What are her options? |
No long-term care policy, contract, or certificate may use waivers to exclude, limit, or reduce benefits for a specifically named or described preexisting disease or physical condition. |
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Long-term care is primarily: |
Personal care |
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What are Medicare Supplement Plan A core benefits? |
- Part A coinsurance/copayment (not Part A deductible) -Part A hospital costs up to an additional 365 days after Medicare benefits are used up -Part A hospice care coinsurance/copayment -Part B coinsurance/copayment -The first 3 pints of blood("blood deductible" for Parts A and B) |
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What are the Medicare Supplement Plan B benefits? |
Core benefits + Medicare Part A deductible |
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What are the Medicare Supplement Plan C benefits?
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-Core benefits -Medicare Part A deductible -SNF coinsurance -Medicare Part B deductible and the foreign travel benefit |
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What are the Medicare Supplement Plan D benefits? |
-Core benefits -Medicare Part A deductible -SNF coinsurance -Foreign Travel benefit |
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What are the Medicare Supplement Plan F benefits? |
-Core benefits -Medicare Part A deductible -SNF coinsurance -Medicare Part B deductible -100% of Medicare Part B excess charges -Foreign Travel Benefit |
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What are the Medicare Supplement Plan G benefits?
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-Core benefits -Medicare Part A deductible -SNF coinsurance -100% of Medicare Part B excess charges -Foreign Travel Benefit This plan must pay for services of activities of daily living that Medicare doesn't cover |
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What are the Medicare Supplement Plan K benefits?
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-includes 50% of the Medicare Part A deductible and 50% of skilled nursing facility coinsurance |
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What are the Medicare Supplement Plan M and N benefits?
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-Core benefits-Medicare Part A deductible-SNF coinsurance-Foreign Travel benefit
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A long-term care policy may condition benefits on: |
The ability to perform activities of daily living |
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According to the North Carolina asset rules for Medicaid insured, the look-back period for assets transferred to an individual is |
60 months. |
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What is the blood benefit for Medicare Part A? |
Will cover all but the first 3 pints of blood received in the hospital. the cost of the first 3 pints of blood is considered a deductible. |
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A patient is considered homebound if the patient : |
is normally unable to leave home. (may attend religious services and medical treatments) |
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An individual long-term care insurance policyholder has the right to return the policy for a full refund of premium within 30 days of the policy |
Delivery to the insured |
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In long-term care insurance, what is the minimum amount per day that must be offered for home health care benefits? |
Home health care benefits shall be offered in an amount of not less than $25 per day. |
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The company can never raise premiums. What kind of policy is this? |
Noncancellable and guaranteed renewable |
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A long-term care policy may exclude or limit coverage for: |
*illness *treatment *services for which benefits are available under Medicare |
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The incontestable period for long-term care policy is |
2 years |
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North Carolina requires the company to obtain one of the following for an applicant age 80 or older: |
*physical examination report *assessment of functional capacity *an attending physician's statement *copies of medical records |
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Group health plans of employers of how many employees are required by law to offer workers and their spouses who are age 65 or older the same health benefits that are provided to younger employees? |
20 or more employees (less than 20 employees Medicare pays primary) |
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What is the Medicare Payment System? |
Prospective Payment System (PPS) *Diagnostic Related Groups(DRGs) - reimbursement to hospitals from a cost basis to a prospectively determined fixed-price system in which hospitals are paid |
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What are the Quality Improvement Organizations? (QIO) |
Utilization and Review Committee - a system for reviewing the appropriateness and efficient allocation of health care services and resources that are being given or are proposed to be given to an insured. |
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What is a Medicare Administrative Contractor (MAC)? |
An intermediary that performs medical reviews to ensure that items or services are covered and are reasonable and necessary. Review claim info to address potential fraud, waste and abuse. |
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Medicare conditional payments are made by Medicare for medical treatment when an insurer has an obligation to make such a payment, but does not. |
Subrogation |
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A skilled nursing care and certain other health care services the patient receives at home for treatment of an illness or injury |
Home Health Care |
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What are the different types of Medicare Advantage Plans? |
*HMO *PPO *Private Fee For Service (PFFS) *Special Needs Plans (SNPs) *Medical Savings Accounts (MSAs) |
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In order to be eligible for Part D a person must: |
be enrolled in Medicare Part A and B |
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A what true out-of-pocket amount starts the coverage gap for Part D coverage? |
$3310; Enrollee then pays 45% for brand-name or 65% for generic drugs until reaching $4850 |
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At what amount does Catastrophic coverage begin for Part D coverage? |
$4850; Medicare then pays 95% of drug costs |
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What is a Prescription Stand-Alone Plan? |
*Prescription drug plan that is separate from Medicare Part A and B. *Offered through private plan *This plan can be added to Original Medicare and some Medicare Advantage plans |
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What is a Medicare Advantage Prescription Drug Plan? |
Medicare Prescription Drug Plan that is received through a private health plan (HMO, PPO), provides more benefits and lower cost through a network of doctors and hospitals. |
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How do Employer Sponsored Retiree Plans work with Medicare Part D? |
*Employers may provide additional coverage to supplement the Medicare drug plan *Employers may make special arrangements with a particular drug plan |
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If an enrollee has Medicare and Medicaid where should they enroll for Prescription Drug coverage? |
They should enroll in Medicare Part D for prescription drug coverage. (Medicaid may cover some prescription vitamins) |
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To buy a Medigap policy the applicant must: |
have Medicare Part A and B. |
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What are the optional Medicare supplement policy benefits? |
*Skilled Nursing Coinsurance *Medicare Part A deductible *Medicare Part B deductible *Medicare Part B excess charge *Foreign Travel Emergency *Extended Drug Benefit *Preventive care |
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On Medigap policies, what is the Medicare Part B Excess Charge? This benefit is on Plans F and G. |
The difference between a doctor or other health care provider's actual charge and Medicare's approved payment amount. If provider does not accept Medicare and charges more than the approved amount, this benefit will pay the excess charge. |
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What type of policy is this? The insurance company cannot cancel or nonrenew coverage except for nonpayment of the premium or because of material misrepresentation on the application. |
Guaranteed Renewable |
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This type of policy is one in which there is nothing about the contract that can be changed, including the premium, and the policy cannot be canceled by the insurer. |
Noncancellable |
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What is the pre-existing condition for Medigap policies? |
*Medigap insurance can refuse to cover a health problem that was diagnosed or treated 6 months before the Medigap policy began. *If the insured had less than 6 months of creditable coverage, this waiting period will be reduced by the number of months of creditable coverage. |
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What is Loss Ratio? |
The ratio of premiums collected to claims paid. |
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What is the Minimum Loss Ratio for Medigap policies? |
Insurers must return 80% of the premiums in the form of benefits |
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What provision gives the issuer the right to change premium and any automatic renewal premium increased based on the policyholder's age. |
Renewal or Continuation Provision (found on first page of the policy) |
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What is the Free-look period? |
The policyholder has the right to return the policy within 30 days of its delivery and to have the premium refunded if the insured is not satisfied for any reason. |
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What provisions are printed on the front page of all Medicare Supplement policies? |
*Renewal or continuation provision *Free-look period |
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Medigap does not cover the following: |
*long-term care *vision *dental care *hearing aids *private-duty nursing *unlimited outpatient prescription drugs *skilled care in a nursing home <100 days *custodial nursing home care at any time |
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What happens to the premiums for Attained Age Rated Medigap policies? |
Premium goes up on policies as the policyholder gets older. |
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What happens to the premiums for Issue Age Rated Medigap policies?
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Premium is based on the age policyholder's age at the time of issue and do not automatically change as the insured gets older. |
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Medicare Supplement Plans Open Enrollment period is a : |
6-month period that guarantees the applicants the right to buy Medigap once they sign up for Medicare Part B. |
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How many days does a person have to purchase a Medigap plan after leaving an employer plan without there being a waiting period for pre-existing condition? |
63 days |
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Who has to provide approval for all advertisement for Medicare Supplement policies? |
The Insurance Commission |
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What type of supplemental policy has a restricted network provisions - provisions that condition the payment of benefits. |
Medicare SELECT policy |
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The process of subtracting medical bills, that are in excess of an insured's income, over a 6-month period is called Medicaid: |
Spend-down |
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Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for what reason? |
For the Spouse living in the community |
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This Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare Services. |
Qualified Medicare Beneficiary (QMB) |
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This Medicaid program pays Medicare Part B premiums for persons entitled to Medicare Part A and whose incomes are slightly higher (up to 20% higher) than the federal poverty level. |
Special Low-income Medicare Beneficiary (SLMB) |
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Long-term Care policies pay benefits by: |
the day, week or month |
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Long-term Care Length of Benefit Period is also referred to as maximum benefit limit. What does it limit? |
It limits the total benefit paid over the life of the policy. This limit may be written in years or dollars. |
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What are the four levels of care for long-term care policies? |
*Skilled Care *Intermediate Care *Custodial Care *Home Health Care |
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What is the elimination period for Long-term care policies? |
Usually 30 days or more in which the insured must be confined in a nursing home facility before benefits will begin. |
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In regards to renewability, all NC long-term care policies must be: |
Guaranteed Renewable |
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What long-term care policy waiver permits the insured to stop paying the premium once the insured is eligible for benefits and the insurance company has begun to pay benefits. |
Waiver of Premium |
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How does Inflation Protection affect long-term care policies? |
This option has to be presented at the time of purchase of the policy. It gives the insured the ability to purchase a policy that allows the benefit levels to increase with benefit maximums as the cost for care increases. |
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This is an attempt to review the client's income and assets to determine if the minimum suitability standards are met. It must be submitted with an application for long-term care insurance. |
Financial or Suitability Worksheet |
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What must every insurer providing long-term care insurance in North Carolina deliver to every applicant before sale? |
Shopper's Guide |
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What is the policy summary? |
A summation of selected features of an insurance policy prepared and attached to the policy by the insurer for delivery to the insured. |
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What are the minimum and maximum ages for long-term care insurance? |
Minimum age is 18 years old. There is no set max age limit. The higher the age, the higher the premiums. |
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LTC partnerships allow those who have exhausted or at least used some of their private long-term care benefits to apply for what coverage, without having to meet the same means-testing requirements. |
Medicaid |
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No long-term care policy may do the following: |
*Be cancelled, nonrenewed or termed on the grounds of age or deteriorating health *Contain provision establishing new waiting period *Provide coverage for skilled nursing care |
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What are the Medicare Supplement Plan L benefits?
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includes 75% of the Medicare Part A deductible and 75% of skilled nursing facility coinsurance |
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Long-term care insurance policies must provide benefits for at least how many levels of care? |
3 |
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State-only Medicaid programs are |
for people who do not qualify for Medicaid. |
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Medicare Advantage plan that is offered by a private insurance company under contract with the Medicare Program |
Private Fee-for-Service plan |
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An individual that is medically unstable and requires frequent monitoring by a medical doctor or registered nurse has a |
Acute condition |
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A patient eligible for Medicaid is entering a nursing facility. How will his and his spouse's assets and resources be counted? |
All their resources will be combined. |
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People who are eligible for Medicare because of end-stage renal disease are not eligible for |
Special enrollment in Part B |
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A long-term care policy may condition benefits on |
The ability to perform activities of daily living |
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The informational brochure for direct response insurance policies may be delivered |
Upon request of the prospective insured but no later than at the time of delivery |
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A retiree who turned 65 on February 1 waits until October to enroll in Medicare Part B. What are the consequences of this delay? |
He missed the Medicare Part B initial enrollment period. |
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What are the Medicare payment options for hospice? |
*No deductible *Copayment of $5 for outpatient prescription drugs for pain relief only |
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What is the total lifetime benefit in days for psychiatric inpatient hospital care? |
190 days |
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What are the required disclosures for Medigap policies? |
*Riders and endorsements *Pre-existing Condition Limitations *Free Look Period *Buyer's Guide *Policy Modifications |
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What does enrollee pay for SNF? |
* 1-20 days = $0 after deductible * 21-100 = $161 per day * 100 + = Patient pays 100%. Medicare does not pay |
