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 Sooner
or later, most of us will rely on Medicare services. This web site is
designed to give you a general overview of how the program works and the
coverage choices available to you. The program includes the Original
Medicare Plan and several Medicare + Choice Plans, such as managed care
plans and fee-for-service plans. AFA encourages you to consider these
options carefully. When first introduced, many of the Medicare + Choice
programs offered greater benefits than the Original Medicare Plan. Now,
however, some insurance firms are finding it difficult to provide these
services at a profit and are cutting back on benefits and geographic areas
in which they provide services. Other firms have withdrawn from the program
completely.
This summary of Medicare benefits is based on information available on the
Medicare web site in the Spring of 2003. AFA encourages you to go to
www.medicare.gov or call
1-800-633-4227, which is available 24 hours a day, including weekends, to
obtain specific information concerning your personal situation.
What is Medicare?
It is our nation's health insurance program for individuals who are age 65 or older, some disabled persons under age 65 and anyone who has permanent kidney failure. It is financed by payroll taxes paid by workers and their employers as well as monthly premiums paid by beneficiaries. It has two parts. Medicare Part A helps pay for care in a hospital or medical care in a skilled nursing facility, for home health care, and for hospice care. Medicare Part B helps pay for doctors, out-patient hospital care, and other medical services.
Who qualifies for Medicare?
Most people age 65 or older qualify for Medicare Part A hospital insurance without paying a monthly premium. You are eligible if: you receive, or are eligible to receive, Social Security based on your benefits or those of a parent or spouse (including a divorced spouse, widow, widower, divorced widow, or divorced widower); you receive, or are eligible to receive, railroad retirement benefits; or, you or your spouse worked long enough in a government job where Medicare taxes were paid.
You can qualify for Medicare before you reach the age of 65 if: you have
been entitled to Social Security disability benefits for 24 months; you get
Social Security disability benefits and have Lou Gehrig's disease; you
receive a railroad retirement disability annuity and meet certain
conditions; or, you or your spouse worked long enough in a government job
where Medicare taxes were paid and you meet the requirements of the Social
Security disability program.
There are special rules for people with kidney failure. You may be eligible
for free hospital insurance at any age if you receive maintenance dialysis
or a kidney transplant, and, if you are either eligible for Social Security
or railroad retirement benefits, or, have worked long enough in a government
job to be insured for Medicare. Your spouse or child with permanent kidney
failure may be eligible based on your work record.
If you do not meet these conditions, you can still get Medicare hospital
insurance by paying a monthly premium if you are 65 or older and a citizen
or a lawful alien who has lived in the US for at least five years.
Anyone who is eligible for free Medicare hospital insurance can enroll in
Medicare Part B medical insurance. This part of Medicare is voluntary; you
have to pay a monthly premium for it. If you are not eligible for the free
hospital insurance program, you can buy medical insurance, without having to
buy hospital insurance, if you are age 65 or older and a citizen or a
lawfully admitted alien who has lived in the US for at least five years.
What specific services does Medicare Part A Hospital Insurance cover?
Medicare pays for all covered hospital services for the first 60 days of a benefit period except for the deductible you must pay. For days 61 through 90, you are required to pay a daily coinsurance. If you need more than 90 days of continuous hospitalization, you can use one or more of your 60 lifetime reserve days. You are also required to pay daily coinsurance for reserve days.
Inpatient care is divided into benefit periods; a benefit period begins the
day you enter the hospital; it ends when you have been out of the hospital
or facility providing skilled care for 60 days in a row. If you are out of
the hospital for more than 60 days and then go back in, you begin a new
benefit period and pay another deductible.
If you need inpatient skilled nursing or rehabilitation services after a
hospital stay and you meet certain other conditions, Part A Medicare helps
pay for up to 100 days in a Medicare-participating skilled nursing facility
in each benefit period. A daily coinsurance payment is required after the
first 20 days. It is important to note that Medicare does not pay for
"custodial care" in nursing homes, e.g. care like help dressing and eating
which does not require the assistance of skilled medical personnel.
Medicare can pay the full approved cost of home health visits from a
Medicare participating home health agency if your health problems cause you
to stay at home and you meet certain other conditions. Part A Medicare
covers part-time or intermittent services of home health aides, occupational
therapy, physical therapy, medical social services, and medical supplies and
equipment.
Medicare helps pay for hospice care provided by a Medicare-certified
hospice, as long as your doctor certifies you are terminally ill and
probably have less than six months to live. As a hospice patient you get
care for two 90-day periods followed by an unlimited number of 60-day
periods so long as your doctor recertifies that you are terminally ill.
What specific services does Medicare Part B cover?
After you pay an annual deductible, Medicare generally pays 80% of the
approved charges for covered services for the rest of the year. Coverage
includes:
- inpatient medical care;
- outpatient hospital care;
- inpatient and outpatient hospital supplies;
- ambulance services;
- X-rays;
- laboratory tests;
- durable medical equipment such as wheelchairs and home orthopedic beds;
- services of certain specially qualified professionals that are not
doctors;
- physical and occupational therapy;
- speech therapy;
- partial hospitalization for psychiatric medical attention;
- home attention if you don't have part A;
- blood;
- yearly mammograms;
- Pap smears;
- pelvic and breast examinations;
- diabetes glucose monitoring and education;
- colorectal cancer screenings;
- bone mass measurements; and
- flu and pneumococcal pneumonia shots.
How can I get more detailed information about Medicare coverage?
You can obtain a copy of Your Medicare Benefits by going to
www.medicare.gov and clicking on publications or by calling the Medicare toll-free number 1-800-633-4227.
What medical services are not covered by Medicare?
It does not cover most nursing home care, dental care and dentures, routine checkups, most immunization shots, most prescription drugs, routine foot care, eyeglasses and hearing aids, personal comfort items (such as a phone or TV in your hospital room), and services outside the US.
What payments must I make when I receive Medicare services?
If you are hospitalized, you will be required to pay a deductible; you must pay coinsurance if your stay lasts beyond 60 days. If you receive medical services from a doctor, you pay a yearly deductible as well as coinsurance for each visit. Monthly premiums, deductibles and coinsurance for Medicare change on an annual basis. You can find out the current amount of these charges by contacting your local Social Security office or calling Social Security's toll-fee number 1-800-772-1213..
When should I sign up for Medicare?
If you are receiving Social Security retirement or disability benefits or railroad retirement checks before age 65, you will be contacted a few months before you become eligible for Medicare. If you are not already receiving these benefits, the Social Security Administration encourages you to contact them about three months before your 65th birthday. You can call 1-800-772-1213 to set up an appointment at any convenient Social Security office. They can help you decide if you should sign up for Medicare Part B. (You will be enrolled in Part A automatically.)
What if I delay enrollment in Part B Medicare? Is there a penalty?
You have seven months, beginning three months before your 65th birthday, to decide about enrollment. If you don't enroll in Medicare Part B when you become eligible initially, or if you drop coverage at some point, you have another chance to sign up each year during a "general enrollment period" from January 1 to March 31. Your coverage begins the following July. However, your monthly premium increases ten percent for each 12-month period you were eligible but didn't enroll, unless you are covered by an employer's plan due to your or your spouse's active employment.
What if I'm still covered under an employer group health plan?
If you are 65 or older and are covered under a group health plan either from your own or your spouse's current employment, you have a "Special Enrollment Period". You can delay enrollment without having to pay the surcharge or waiting for a general enrollment period. You can enroll in Part B Medicare any time while you are covered under the group health plan or during the eight-month period that begins with the month your group health coverage ends or the month employment ends C whichever comes first.
If you delay enrollment until your employer-provided group health plan coverage is about to stop, you will be in a position to take advantage of the one-time Medigap open enrollment period described below.
What is the one-time "Medigap open enrollment period"?
When you enroll in Medicare Part B, you trigger a one-time "Medigap open enrollment period." It is a six month period in which you have the right to buy the Medigap policy of your choice regardless of any health problems you may have. A company cannot refuse you a policy or charge you more than it charges others during this period. There are ten standard plans labeled Plan A through Plan J; each offers a different combination of benefits.
If you have retiree health care coverage under your contract, you may not need Medigap coverage.
You can get more information about Medigap policies from the publication Medicare Supplemental Insurance, Medigap Policies and Protections or Guide to Health Insurance for People with Medicare by going to
www.medicare.gov and clicking on publications or by calling the toll-free Medicare number. AARP has produced a comprehensive report explaining the different plans available. You can find it at
www.aarp.org/hcchoices/medicare/supplement/coverageb.html .
What are my choices for Medicare coverage?
Under the Original Medicare Plan, you can visit the hospital, doctor, or health care provider of your choice who accepts Medicare patients. You are responsible for the deductibles and coinsurance payments Medicare does not cover. You can secure additional coverage under one of 10 Medigap policies.
Medicare Managed Care Plans must provide all hospital and medical benefits covered by Medicare; usually you are required to obtain services from the plan's network of health care providers. You are required to enroll in Medicare Part B and pay your monthly premiums.
In Private Fee-for-Service Plans, Medicare pays a set amount of money to the private insurance company every month. The insurance company decides how much you pay for the services you receive on a pay-per-visit arrangement.
Medicare has produced a variety of publications to help you compare these plans. They include Medicare and You, Guide to Health Insurance for People with Medicare, Understanding Your Medicare Choices, and Worksheet for Comparing Medicare Health Plans. To get a copy of these publications, go to
www.medicare.gov and click on publications or call the Medicare toll-free number.
What if I have a private insurance plan?
It is a good idea to get in touch with your insurance agent to see how your private plan fits with Medicare medical insurance. This is especially important if you have family members covered under the same policy. It is important not to cancel any health insurance you have until your Medicare coverage actually begins.
Can I appeal a decision by a Medicare provider to deny me payments for services?
Yes. You have a right to services that are reasonable and necessary. If you are denied coverage for a service you think is necessary, you have a right to appeal the decision. A description of how the appeal process works, for both original Medicare and Managed Care Plans, is available on the AARP web site at
www.aarp/hcchoices/medicare/rights/rightto.html .
Is there special assistance for low-income Medicare beneficiaries?
If your assets (bank accounts, stocks and bonds) do not exceed $4,000 (or $6,000 for a couple), you have Part A insurance and a limited income, you may qualify for programs administered by individual states. You can contact your state or local medical assistance (Medicaid) agency, social service or welfare office to find out if you or a loved one qualify.
Can I get Medicare coverage if I am disabled but still working?
Yes. The Ticket to Work and Work Incentives Improvement Act of 1999 expands Medicare coverage for disability beneficiaries who work. Premium free hospitalization coverage is available for four and a half years beyond the initial 39 months of coverage. For more information about how this program works, call 1-800-722-1213 or go to
www.ssa.gov/work
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