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Business Math17th EditionMary Hansen 3,734 solutions Medigap -standard Medicare Supplement plans -policies issued by PRIVATE insurance companies that are designed to fill in some of the GAPS in Medicare -designed to fill the GAP in coverage attributable to Medicare's deductibles, copayment requirements, and benefit periods -these plans are NOT administered through the federal Social Security program, as is Medicare, but instead....... -these policies must meet certain requirements and must be approved by the state department of insurance -Medicare Supplement policies pay some or all of Medicare's deductibles and copayments Medigap Requirements -to buy a xxxxxxx policy, the applicant must generally have Medicare Part A and Part B -if the applicant is under age 65 and not disabled or does not have End-Stage Renal Disease (ESRD), the applicant may NOT be able to buy a Medigap policy until age 65 "Educational Highlights" -Medigap policies are available to anyone who qualifies for Medicare and they have an open enrollment period During open enrollment, an applicant cannot be denied on the basis of health status, claims history, or medical condition during the first 6 MONTHS after they enroll in Medicare Part B -there are 10 Medicare Supplement benefits plans, labeled A through N -Plan A is the only plan that absolutely must be provided if an insurance company offers Medigap; it contains the core benefits that must be included in all cases Core Benefits: -Plans B through N add benefits that build on supplement plans A and B Omnibus Budget Reconciliation Act (OBRA) -in 1990, congress passed the Omnibus Budget Reconciliation Act. -purpose of the act was to STANDARDIZE MEDIGAP POLICIES -most states have adopted these recommendations Medigap: Standardized Benefits -the NAIC has developed standard Medicare Supplement benefit plans which are identified with letters A through N -the core benefits found in Plan A MUST be offered in all the plans, and the other plans have a variety of additional benefits -PLan A must be offered by any insurer marketing Medigap plans, while the other plans are optional Core Benefits -AKA Basic Benefits Cover the following deductibles and coinsurance of Medicare: -1.) Part A coinsurance/copayment (NOT Part A
deductible) Medigap: Plan A -Medicare Supplement (Plan "X") provides ONLY the core benefits Medigap: Plan B -core benefits Medigap: Plan C -core benefits Medigap: Plan D -core benefits Medigap: Plan F -core benefits Medigap: Plan G -core
benefits -this plan MUST pay for services of activities of daily living (ADL) that Medicare doesn't cover Medigap: Plans E, H, I and J -these Medigap plans are no longer available -if an insured has already purchased one of those plans, they can still keep them Medigap: Plan K -a lower premium plan with higher out-of-pocket costs -includes 50% of the Medicare Part A deductible and 50% of skilled nursing facility coinsurance The core benefits are different in this plan: -1.) approved hospital costs for the copayments for days 61-90 in any Medicare benefit period (same as Plans A-G). Approved hospital costs for the copayments for lifetime reserve days 91 through 150 (same as Plans A-G) -2.) approved hospital costs for an additional 365 days after all Medicare benefits are used (same as Plans A-G) -3.) 50% of charges for the first 3 pints of blood in Plan "x", 75% of charges for the first 3 pints of blood in Plan "L" -4.) 50% of Part B coinsurance amount in Plan "x", 75% of Part B coinsurance amount in plan "L" -5.) 50% of hospice cost-sharing and respite care expenses for Part A in Plan "x", 75% of hospice cost-sharing and respite care expenses for Part A in Plan "L" Medigap: Plan L -a lower premium plan with higher out-of-pocket costs -includes 75% of the Medicare Part A deductible and 75% of skilled nursing facility coinsurance The core benefits are different in this plan: -1.) approved hospital costs for the copayments for days 61-90 in any Medicare benefit period (same as Plans A-G). Approved hospital costs for the copayments for lifetime reserve days 91 through 150 (same as Plans A-G) -2.) approved hospital costs for an additional 365 days after all Medicare benefits are used (same as Plans A-G) -3.) 50% of charges for the first 3 pints of blood in Plan "x", 75% of charges for the first 3 pints of blood in Plan "L" -4.) 50% of Part B coinsurance amount in Plan "x", 75% of Part B coinsurance amount in plan "L" -5.) 50% of hospice cost-sharing and respite care expenses for Part A in Plan "x", 75% of hospice cost-sharing and respite care expenses for Part A in Plan "L" Medigap: Plans M and N -provide benefits similar to Plan D, but the co-pays and deductibles might be different Medigap: Optional Benefits Medigap Optional Benefits include: -1.) skilled nursing
coinsurance Optional Benefits: Skilled Nursing Coinsurance -Medicare pays all covered costs for the first 20 days of SNF care -after day 20, Medicare pays all but $170.50/day for the 21st-10th day of SNF care -this benefit will pay the coinsurance amount for days 21-100 Optional Benefits: Medicare Part A Deductible -Medicare pays all but a total of $1,364 for days 1-60 of a hospital stay -this benefit will pay the Medicare Part A deductible -Medigap Plans B through G cover the hospital deductible for each benefit period -Plan K covers 50% of the deductible and Plan L covers 75% of the deductible Optional Benefits: Medicare Part B Deductible -Medicare pays nothing for the patient's first $185 yearly deductible of covered services (like doctor services and outpatient hospital care) -this benefit will pay the Medicare Part B deductible -Medigap Plans C and F pay this deductible Excess Charge -the difference between a doctor or other health care provider's actual charge and Medicare's approved payment amount Optional Benefits: Medicare Part B Excess Charge -the excess charge is the difference between a doctor or other health care provider's actual charge and Medicare's approved payment amount -if the doctor does not accept assignment and charges are more than the Medicare-approved amount, Medicare will not pay the difference -the patient pays the total difference between what Medicare pays and the doctor who DOES NOT ACCEPT ASSIGNMENT CHARGES -the doctor can charge UP TO 15% MORE than the Medicare approved amount -if a patient has Plan F, or Plan G, the patient pays none of the excess charge Optional Benefits: Foreign Travel Emergency -generally, Medicare pays nothing for emergency health care outside the United States (some exceptions exist for care in Canada and Mexico) -with this benefit, the patient pays the first $250 and then 20% of the remaining cost of emergency health care during the first 60 days of each trip, with a $50,000 lifetime maximum -Medigap Plans C through G cover some emergency care outside the United States Optional Benefits: Medicare-Covered Preventative Services -some Medicare-covered preventive services waive the Part B deductible -after the insured pays the yearly deductible for Part B, Medicare will pay 75% to 100% of some preventive services under Part B -the insured pays 20-25% for most Medicare covered preventive services -the insured pays nothing for routine yearly check-ups and tests like serum cholesterol screening and diabetes screening -if the insured has this benefit, after paying the yearly deductible for Part B, the insured pays nothing for most Medicare-covered preventive services Renewability: Guaranteed Renewabe -means the insurer MUST renew the policy unless the insured chooses to cancel or stops paying premiums -Medigap policies are REQUIRED BY LAW to be guaranteed renewable -the insurance company cannot cancel or non-renew coverage except for nonpayment of the premium or because of material misrepresentation on the application Renewability: Noncancellable -a policy in which there is nothing about the contract that can be changed, including the premium, and... -the policy cannot be canceled by the insurer -Medigap policies may be made xxxxxxxxxxxxxx Pre-Existing Conditions -a health condition that existed before the date a new insurance policy begins -if the client had a health problem before the Medigap policy began, the Medigap insurance company CAN REFUSE to cover that health problem for up to 6 MONTHS -this is called a "pre-existing condition waiting period" -if the insured purchases a Medigap policy during the Medigap open enrollment period, and the insured had at least 6 months of previous health coverage that qualifies as creditable coverage... -the company canNOT apply a pre-existing condition waiting period to the insured -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 Pre-Existing Condition Waiting Period -a 6 month waiting period where the Medigap insurance company can refuse to cover a clients pre-existing health condition -the insurance company can only use this kind of waiting period if the health problem was diagnosed or treated DURING the 6 months before the Medigap policy began Creditable Coverage -(for Medigap policies) is generally any other health coverage the insured had before applying for a Medigap policy -whether the insured had creditable coverage depends on whether the insured had any breaks in coverage: -the insured can only count creditable coverage that the insured had after that break in coverage -if the insured had one or more breaks in coverage, BUT each break was shorter than 63 days, then the insured can add the periods of coverage together -this WILL count towards the creditable coverage Types of "Creditable Coverage" These types of health
care coverage may count as creditable coverage for Medigap policies: The following does NOT count as creditable coverage: Medigap Minimum Requirements No policy or certificate of Medicare Supplement insurance may be delivered in NC unless an outline of coverage is delivered to the applicant at
the time application is made Required Disclosures: Minimum Requirements: Outline of Coverage -no policy or certificate of Medicare Supplement insurance may be delivered in NC unless an outline of coverage is delivered to the applicant AT THE TIME APPLICATION IS MADE The outline of coverage must include the following: Outline of Coverage: 4 Parts The xxxxxxx of xxxxxxxx consists of 4 parts: Loss Ratios The ratio of: -Premiums Collected/Claims Paid -insurers must file a copy of the master policy and any certificate used in NC Insurers must ANNUALLY file: Minimum Loss Ratio (MLR) -under the Patient Protection and Affordable Care Act (PPACA), insurers must return 80% of the premiums in the form of benefits, called a xxxxxxxxxx xxxx xxxxxx -individual states can request a modification to this rule -as of 2014, NC requires that comprehensive health insurers issuing policies to individuals MUST MEET THE 80% MLR requirement -rates and rating schedules MUST demonstrate anticipated loss ratios -policies solicited BY MAIL OR MASS MEDIA advertising are deemed to be group policies -an issuer must make premium adjustments as are necessary to produce an expected loss ratio that will conform to minimum loss ratio standards Medigap: Required Disclosures -1.) renewal or continuation provision Required Disclosures: Renewal or Continuation Provision -this provision MUST appear on the FIRST PAGE of the policy -includes any reservation by the issuer of the right to change premiums and any automatic renewal premium increases based on the policyholder's age Required Disclosures: Riders and Endorsements -all riders or endorsements which reduce or eliminate benefits or coverage added to a Medicare Supplement policy after date of issue or at reinstatement or renewal MUST require signed acceptance by the insured -big confusing paragraphs Required Disclosures: Pre-Existing Condition Limitations -if a Medicare Supplement policy contains any limitations with respect to pre-existing conditions.... -such limitations must appear as a separate paragraph of the policy and be labeled as "pre-existing condition limitation" Required Disclosures: Free-Look Period -Medicare Supplement policies must have a notice prominently printed on the FIRST PAGE of the policy, or attached to it, stating in substance that... -the policy holder has the right to return the policy WITHIN 30 DAYS of its DELIVERY and to have the premium refunded if, after examination of the policy, the insured is not satisfied for any reason Required Disclosures: Buyer's Guide -issuers of accident and health policies which provide hospital or medical expense coverage on an expense incurred or indemnity basis, other than incidentally, to persons eligible for Medicare by reason of age, must provide such applicants a copy of the Medicare Supplement Buyer's Guide int he form developed jointly by the National Association of Insurance Commissioners (NAIC) and the Center for Medicare and Medicaid Services in a type size no smaller than 12-point type -the Buyer's Guide must be delivered to the applicant AT THE TIME OF APPLICATION and the issue must obtain acknowledgement of receipt of the Buyer's Guide -direct response issuers must deliver the Buyer's Guide to the applicant upon request but NO LATER THAN at the time the policy is delivered Required Disclosures: Policy Modifications -as soon as possible, but NO LATER THAN 30 DAYS prior to the annual effective date of any Medicare benefit changes... -an issuer must notify its policy holders and certificate holders of modifications it has made to Medicare Supplement policies -each policyholder must be informed as to when any premium adjustment is to be made due to changes in Medicare -issuers must provide an outline of coverage to each applicant at the time application is presented tot eh prospective applicant and, except for direct response policies, obtain an acknowledgement of receipt of such outline from the applicant Medigap: Exclusions Medigap policies do NOT cover: -Medigap does not cover skilled care in a nursing home BEYOND the FIRST 100 DAYS or custodial nursing home care at any time (for coverage of this type, the patient must either purchase long-term care insurance or qualify for Medicaid coverage) MAY be covered if treatment or equipment is needed as the result of an injury: Medigap Premiums: Attained Age Rate Policies -a type of Medigap policy that charges escalating premiums for the same policy holder as he or she ages -in other words, an insurance company can base the monthly premium on the insured's current age so that the premium goes up each year -the policy premium may also increase because of inflation -the premium always increases as the insured gets older -premiums may be lower initially, but in the long run this type of policy may be more expensive than an issue age policy Medigap Premiums: Issue Age Policies -with the xxxxx xxx method of premium calculation, if an insured was 65 when the policy was purchased...... -the insured will always pay the premium the company charges people who are 65, regardless of the insured's age -premiums are based on the insured's age at the time of issue and do not automatically increase as the insured gets older -premiums can increase annually with rising health care costs, but the rate of increase may be lower than with an attained age plan Medigap: Compensation -first-year commissions and other first-year compensation received on the sale of Medigap policies may not exceed 200% of the second-year commission or other second-year compensation -commissions and other compensation paid in renewal years must be the same as the amount paid in the second year -renewal commissions/compensation MUST be paid for at least 5 renewal years -the regulation prohibits representatives from earning first-year compensation on replacement sales of Medigap policies UNLESS the replacement policy provides greater benefits to the insured Guaranteed Enrollment: Open Enrollment -a 6-month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare Part B -anyone who qualifies for Medicare may also purchase a Medicare Supplement and pay the necessary premium for those additional benefits -under OBRA, Medicare supplement insurance may not discriminate in pricing or be denied on the basis of an applicant's health status, claims experience, receipt of health care, or medical condition -in essence, to buy a Medigap policy, the applicant must generally have both Medicare Part A and Part B Upon Leaving Medicare Advantage (MA) Programs -persons who have enrolled in MA do not need a Medicare Supplement policy as Medicare Advantage is medicare and Medicare supplement combined in a single program -if a person disenrolls, he or she becomes subject to those copayments and limitations of Medicare, unless the person has purchased a Medicare supplement -when you look at the plain Medicare coverage, for hospitalization, without the Advantage plan or a Medicare supplement, the amount paid IS BASED UPON THE NUMBER OF DAYS THE PATIENT IS HOSPITALIZED -the Medicare Advantage plan or Medicare supplement picks up those limitations General Statutes: Applicant -in the case of an individual Medicare Supplement policy or subscriber contract, the xxxxxxxxx is the person who seeks to contract for insurance benefits -in the case of a group Medicare Supplement policy or subscriber contract, the xxxxxxxx is the proposed certificate holder General Statutes: Certificate -any xxxxxxxxx issued under a group Medicare Supplement policy which has BEEN DELIVERED or ISSUED FOR DELIVERY in this state General Statutes: Policy -a Medicare Supplement xxxxx is a group of individual policy or accident and health insurance that is advertised, marketed, or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical, or surgical expenses of persons eligible for Medicare General Statutes: Scope of Provisions -North Carolina regulations apply to all Medicare Supplement (Medigap) policies issued for delivery in this state on or after the August 7, 1989; and all certificates issued under group Medicare supplement policies, which certificates have been delivered or issued for delivery in this state -duplicating Medicare benefits Scope of Provisions: Duplicating Medicare Benefits -no policy can duplicate Medicare benefits Scope of Provisions: Pre-Existing Conditions -a policy may not deny a claim for losses incurred more than 6 months from the effective date of coverage for a pre-existing condition -a policy may not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received forma physician within 6 months BEFORE the effective date of coverage Scope of Provisions: Loss Ratio Standards and Filing Requirements Every insurer providing group Medicare Supplement insurance benefits to North Carolina residents MUST file: Every insurer providing policies or certificates in this State must ANNUALLY file its: Scope of Provisions: Disclosure Standards -no Medicare Supplement policy may be delivered in this state unless an "outline of coverage" was provided to the applicant at the time of applicant -the "outline of coverage" must follow the format and content prescribed by the commissioner -the commissioner may require an "information brochure" to be provided to prospective insureds eligible for Medicare with the outline for coverage -all solicitation materials must clearly indicate that the premiums are based on attained age, which means those premiums will increase each year Scope of Provisions: Notice of Free Examination -must have a notice prominently printed on the first page of or attached to the policy or certificate stating that the applicant has the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy, the applicant is not satisfied for any reason -any refund must be paid DIRECTLY TO THE APPLICANT by the insurer in a timely manner Scope of Provisions: Filing Requirements for Advertising -every insurer must provide a copy of any Medicare Supplement advertisement to the Commissioner for review or approval, whether the advertisement is through written, ratio, or television medium Scope of Provisions: Penalties -if the Commissioner finds that any person has violated or is violating any of these provisions, he/she may require the person to either: -1.) cease marketing any policy in this state that is directly or indirectly related to the violation, or Scope of Provisions: Eligibility by Reason of Disability -an insurer may develop premium rates specific to the disabled population -rates and applicable rating factors MUST be filed with and approved by the Commissioner -insurers MAY discriminate in the pricing of Medicare Supplement plans because of: ****IF****** -the application is submitted during an open enrollment or is submitted within 63 days after the termination of a managed care plan Scope of Provisions: Compliance with Federal Law Regulations The Commissioner may adopt temporary rules necessary for Supplement policies to conform to requirements of Federal law and regulations, including the following: 1.) requiring refunds or credits if the policies do not meet loss ratio requirements Standards for Claims Payment -1.) an issuer must accept a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required -2.) payment determination must be made on the basis of the information contained in that notice -3.) the issuer must then notify the physician or supplier and the beneficiary of the payment determination and pay the participating physician or supplier directly -at the time of enrollment, issuers must furnish each enrolled with a card listing the: -issuers must provide to the Secretary of Health and Human Services, AT LEAST ANNUALLY, a central mailing address to which all claims may be sent by Medicare carriers Requirements for Application Forms -the following statements must appear on an application for Medicare Supplement insurance: SEE PAGE 13 -the following questions must appear on an application for Medicare Supplement insurance: SEE PAGE 14 -agents must list any other health insurance policies they have sold to the applicant which are still in force or that were sold in the past 5 YEARS which are no longer in force Medicare Policy Replacement -if a Medicare Supplement policy replaces another Medicare Supplement policy, the replacing issuer must waive any time periods applicable to: -if a Medigap policy replaces another Medigap policy that has been in effect for at least 6 MONTHS, the replacing policy will NOT provide any time periods, or probationary periods -a separate charge may not be made to the applicant for the waiver of the pre-existing condition -if the new policy replaces an existing policy, a "Notice to Applicant Regarding Replacement of Medicare Supplement Insurance" must be provided to the applicant Standards for Marketing Example on Page 15 Marketing: Prohibited Actions -twisting Twisting -knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or issuers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender.....or convert any insurance policy, or to take out a policy of insurance with another issuer High Pressure Tactics -employing any method of marketing having the effc of or tending to induce the purchase of insurance through: Cold Lead Advertising -making direct or indirect use of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance agent or insurance company Appropriateness of Recommended Purchase -any sale of Medicare Supplement coverage that will provide an individual with MORE THAN ONE Medicare Supplement policy is PROHIBITED Compensation -consideration or remuneration of any kind relating to the sale or renewal of a Medicare Supplement policy including:
Representative Includes an: Filing and Approval of Policies/Certificate and Premium Rates -premium rates for each policy must be filed and approved by the Department of Insurance, and -insurance carriers are required to state in their filing the minimum anticipated loss ratios -the minimum for individual policies is 65%, and for group policies, 75% -an issuer may discontinue the availability of a policy form or certificate form if the issuer provides the Commissioner written notice of the decision at least 30 DAYS BEFORE DISCONTINUING availability -the discontinued form may not be re-submitted for approval for 5 YEARS -the sale or transfer of a Medigap business to another issuer is considered a DISCONTINUANCE Medicare SELECT Policies and Certificates -a Medicare Supplement (Medigap) policy that contains restricted network provisions (provisions that condition the payment of benefits, in who or in part, on the use of NETWORK PROVIDERS -these plans negotiate with a provider network of doctors, hospitals and specialists to charge lower rates for medical services -it essentially operates like an HMO -these lower rtes keep costs down for the SELECT plan provider, and plan members pay lower premiums -each Medicare SELECT policy must be approved by the head of a State's Department of Insurance -currently, issuers are not allowed to sell new Medicare SELECT policies to individuals whose primary residence is located outside of the issuer's service area Medicare SELECT Required Features Every Medicare SELECT policy must do the following: -1.) provide payment for full coverage under the policy for covered services not available through network providers -2.) not restrict payment for covered services provided by non-network providers if the services are for symptoms requiring emergency care and it is not reasonable to obtain such services through a network provider -3.) make full and fair disclosure in writing of provisions, restrictions, and limitations of the Medicare SELECT policy to each applicant -4.) make available upon request the opportunity to purchase a Medicare Supplement policy offered by the issuer which has comparable benefits and does not contain a restricted network provision. These policies must be available without requiring evidence of insurability if the Medicare SELECT policy has ben in force for 6 months; and -5.) provide for continuation of coverage int eh event that Medicare SELECT policies are discontinued to to the failure of the Medicare SELECT program Medicare SELECT Continued... -Medicare SELECT policies must provide for emergency care available 24 HOURS a day and 7 DAYS/week, and keep written agreements with network providers describing specific responsibilities Providers must also provide insureds with the following information: Medicare SELECT: Complaint -any dissatisfaction expressed by an individual concerning a Medicare SELECT issuer or its network providers Medicare SELECT: Grievance -dissatisfaction expressed in writing by an individual insured under a Medicare SELECT policy with the administration, claims practices, or provisions of services concerning a Medicare SELECT issuer or its network providers Medicare SELECT: Medicare SELECT Issuer -an insurance company offering or seeking to offer a Medicare SELECT policy Medicare SELECT: Medicare SELECT Policy -a Medicare supplement policy that contains restricted network provisions Medicare SELECT: Network Provider -a provider of health care, or a group of providers of health care, which has entered into a written agreement with the issuer to provide benefits insured under a Medicare SELECT policy Medicare SELECT: Restricted Network Provision -any provision which conditions the payment of benefits, in whole or in part, on the use of network providers Medicare SELECT: Service Area -the geographic area approved by the Commissioner within which an issuer is authorized to offer a Medicare SELECT policy |
Which of the following is a requirement for standard Medicare supplement plans Quizlet
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