Medicare: The Basics

What is Medicare?

ü  Medicare is an insurance program for people ages 65 and older, and for people younger than 65 who have been diagnosed with a permanent disability.

What are the different parts and what do they cover?

ü  Part A: Is also known as Hospital Insurance (HI) program. Part A covers hospital visits, skilled  nursing facilities, health services received in the home, and end-of-life care (hospice care). You might not pay a premium depending on if you paid Medicare taxes when you worked.

ü  Part B: Is also known as the Supplementary Medical Insurance (SMI) program. Part B helps pay for physician, outpatient, health services received in the home. You will need to pay a monthly premium.

ü  Part C: Is also known as Medicare Advantage program. Part C allows beneficiaries to enroll in a plan offered by a Medicare-approved private insurance company. The plans must provide at least the same coverage as Part A, Part B and will also usually provide prescription drug coverage for additional cost.

ü  Part D: is the prescription drug option. This is usually provided by Medicare-approved private insurance companies. You will have to pay a monthly premium.

What is not covered by Medicare?

Unfortunately, Medicare does not cover all of your healthcare needs. Some of the services not covered by Medicare include:

o   alternative medicine, such as acupuncture

o   most care received outside of the United States

o   cosmetic surgery

o   dental care – unless it is connected to care that is covered (such as oral examination before kidney transplant)

o   hearing aids

o   personal care such as help bathing or dressing (unless homebound or in a skilled nursing facility)

o   non-medical services such as hospital telephone, copies of x-rays

o   vision care – unless it is related to eye diseases, such as glaucoma, or is a medical emergency

How do I qualify?

ü  You must be a US Citizen. When you work, you contribute taxes from your paycheck to Medicare. Generally, if you are eligible for Social Security benefits, you will automatically receive Part A and Part B when you turn 65. If you are under 65 and disabled, you will automatically eligible for Medicare after receiving Social Security Disability Income (SSDI) for 24 months.

ü  For most individuals who receive Part A, enrollment in Part B is automatic. If you don’t want Part B, remember to follow the instructions on your Medicare card to remove it.

ü  If you do not yet receive Social Security benefits (for instance if you are still working), you will have to sign up yourself for Part A and Part B. Be sure to sign up early for benefits – you should sign up with Social Security 3 months before you turn 65, or else your coverage will be delayed and you might have to pay a higher premium. SO BE SURE TO ENROLL THREE MONTHS BEFORE YOU TURN 65!

ü  Once you are enrolled in Part A and/Part B, you can also enroll in Part D for prescription drug coverage. The enrollment period for Part D will be between October 15 and December 7.

ü  Individuals who are eligible for both Parts A and B can also choose to enroll in Part C instead. The enrollment period for Part C runs from October 15 to December 7.

How to enroll

ü  You must be a US Citizen. When you work, you contribute taxes from your paycheck to Medicare. Generally, if you are eligible for Social Security benefits, you will automatically receive Part A and Part B when you turn 65. If you are under 65 and disabled, you will automatically eligible for Medicare after receiving Social Security Disability Income (SSDI) for 24 months.

ü  For most individuals who receive Part A, enrollment in Part B is automatic. If you don’t want Part B, remember to follow the instructions on your Medicare card to remove it.

ü  If you do not yet receive Social Security benefits (for instance if you are still working), you will have to sign up yourself for Part A and Part B. Be sure to sign up early for benefits – you should sign up with Social Security 3 months before you turn 65, or else your coverage will be delayed and you might have to pay a higher premium. SO BE SURE TO ENROLL THREE MONTHS BEFORE YOU TURN 65!

ü  Once you are enrolled in Part A and/Part B, you can also enroll in Part D for prescription drug coverage. The enrollment period for Part D will be between October 15 and December 7.

ü  Individuals who are eligible for both Parts A and B can also choose to enroll in Part C instead. The enrollment period for Part C runs from October 15 to December 7.

Where can I get help to pay for Medicare?

If you need help paying for Medicare, ask! Two important programs that can help you pay for your healthcare are:

o   The Extrahelp program can help pay for your prescription drug costs. To be eligible, you will need to meet resource and income limits set by the Social Security Administration. In general, your resource limit must be no greater than $12,640 for an individual (or $25,260 for a couple) in assets, and no greater than $16,335 for an individual (or $22,065 for a couple) in income. (Partners were unclear about this sentence).

o   The Medicare Savings Program can help pay for Medicare Part A and Part B premiums. The requirements for eligibility will vary by state. If you qualify or think you might qualify, check with your state Medicare program. 

What are the changes to Medicare under the new law?

o   HELP with Prescription medication: You should expect some help if you receive a Part D prescription benefit. Brand-name drug costs will be reduced by up to 50%.  Costs for generic drugs will also gradually decrease.  

o   FREE check-ups: Preventative care including regular check-ups, screenings and vaccinations will be free for elders and will not require “out-of-pocket” co-payments. An annual wellness exam will also be free.

o   NEW DATES to change plans: the open period to change your plan for 2012 will be October 15, 2011- December 7, 2011. The new coverage will begin January 1.

o   Changes to Medicare Advantage – eliminated???

What if Medicare won’t pay for my care

You have a right to appeal your denial of care if you think the care you received was necessary!

Sometimes denials occur because of billing mistakes. If it is not a billing mistake, the next step is to appeal. Your denial of care will be sent to you through the Medicare Summary Notice (MSN), which will also have instructions on appealing. Be sure to keep photocopies and records of all communication.