📄️ 11.0 Senior Needs
Learning Objectives
📄️ 11.1 Medicare Overview
Medicare is a federal health insurance program originally established to provide hospital and medical coverage primarily for individuals age 65 and older. The program has since been expanded to include coverage for individuals of any age who meet certain qualifying conditions, including:
📄️ 11.2 Part A, Hospital Insurance (Inpatient)
Medicare Part A is funded through payroll taxes, including FICA contributions, and is generally premium-free for individuals who qualify through Social Security, Railroad Retirement, or certain government employment. Individuals age 65 or older who do not meet these qualifications may still obtain Part A coverage by paying a monthly premium.
📄️ 11.3 Part B, Medical Insurance (Physicians, Surgeons, and Outpatient)
Medicare Part B is an optional form of coverage offered to individuals when they become eligible for Part A. Enrollment in Part B requires payment of a monthly premium. After the annual deductible is satisfied, Part B generally pays 80% of covered expenses, while the insured is responsible for the remaining 20% coinsurance. There is no maximum out-of-pocket limit under Part B.
📄️ 11.4 Part C, Medicare Advantage
Medicare Advantage (Part C) plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits, and often include prescription drug coverage. These plans may take the form of Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, and Special Needs Plans (SNPs).
📄️ 11.5 Part D, Prescription Drug Benefit
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) established a voluntary prescription drug program known as Medicare Part D, which is offered through private insurance companies.
📄️ 11.6 Medicare Supplement Insurance (Medigap) Overview
Purpose
📄️ 11.7 Standardized Medicare Supplement Coverage Requirements
The NAIC Model Law with respect to Medicare supplement policies was amended to revise the standardized Medicare Supplement plans delivered or issued for delivery in any state. Plans A, B, C, D, F, F with High Deductible, G, K, L, M, and N are available.
📄️ 11.8 Medicare Supplement Minimum Benefit Standards
Policy Requirements
📄️ 11.9 Medicare Supplement Replacement Requirements
When replacing a Medicare Supplement (Medigap) policy, an agent must:
📄️ 11.10 Medicare Select
Medicare Select is a managed care version of a Medicare Supplement policy, offered through private insurers. These plans must provide the same benefits as standard Medicare Supplement policies, provided the insured uses the plan’s network of approved providers.
📄️ 11.11 Other Options for Individuals with Medicare
Employer Group Health Plans
📄️ 11.13 Medicaid
Medicaid provides financial assistance to individuals with limited income and demonstrated medical need. Eligibility is determined by income levels, which typically range from 133% to 138% of the Federal Poverty Level (FPL), depending on the state, and are adjusted based on household size.
📄️ 11.13 Long Term Care Insurance Overview
Long-Term Care Insurance Defined
📄️ 11.14 Long-Term Care Coverages and Conditions
LTC Facilities and Levels of Care
📄️ 11.15 Long Term Care Minimum Benefit Standards and Exclusions
Each Long-Term Care (LTC) insurance policy is required to include specific consumer protections and standardized provisions. A 30-day free look period must be provided, beginning on the date the policy is delivered. During this time, the applicant has the right to review the policy and return it for a full refund if dissatisfied; upon return, the policy is considered void.
📄️ 11.16 Replacement of Long-Term Care Policies
When recommending the purchase or replacement of a Long-Term Care (LTC) insurance policy, agents must follow established suitability and replacement guidelines. These include the following requirements:
📄️ 11.17 Qualified Long-Term Care Insurance
Favorable tax treatment is available for certain Long-Term Care (LTC) insurance contracts that meet specific eligibility standards. To qualify, the policy must meet all of the following requirements:
📄️ Recap of Chapter Eleven
1. Medicare was originally established to provide limited health care benefits to individuals age 65 and older, as well as those diagnosed with End-Stage Renal Disease (ESRD). Subsequent amendments expanded eligibility to include individuals who have received Social Security Disability benefits for more than 24 consecutive months and those diagnosed with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s Disease. 11.1