What is Medicare?

Medicare is a federal health insurance program for people 65 and older and for eligible people who are under 65 and disabled. Medicare is run by the Centers of Medicare and Medicaid Services, an agency of the U.S. Department of Health and Human Services. It is controlled by Congress.

Medicare was never intended to pay 100% of medical bills. Its purpose is to help pay a portion of medical expenses. Medicare beneficiaries also pay a portion of their medical expenses, which includes deductibles, copayments, and services not covered by Medicare.

There are four parts to Medicare:

  • Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
  • Medical insurance (Part B) helps pay for doctors, many medical services and supplies that are not covered by hospital insurance.
  • Medicare Advantage (Part C) formerly known as Medicare + Choice is available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.
  • Prescription drug coverage (Part D) helps pay for medications doctors prescribe for treatment.

Am I eligible for Medicare?

To receive Medicare, you must be eligible for Social Security benefits.

Part A Eligibility

Most people age 65 or older are eligible for Medicare Part A (Hospital Insurance) based on their own employment, or their spouse’s employment. Most people have enough Social Security credits to get Part A for free. Others must purchase it.

You are eligible for Medicare Part A if you meet one of the following criteria:

  • You are eligible for Social Security or Railroad Retirement benefits, even if you do not receive those benefits.
  • You are entitled to Social Security benefits based on a spouse’s, or divorced spouse’s work record, and that spouse is at least 62 years old.
  • You have worked long enough in a federal, state, or local government job to be eligible for Medicare.

If you are under 65, you are eligible for Medicare Part A if you meet one of the following criteria:

  • You have received Social Security disability benefits for 24 months.
  • You have received Social Security benefits as a disabled widow(er), divorced disabled widow(er), or a disabled child for 24 months.
  • You have worked long enough in a federal, state, or local government job and meet the requirements of the Social Security disability program.
  • You have permanent kidney failure that requires maintenance dialysis or a kidney transplant.
  • You are diagnosed with ALS or Lou Gehrig’s disease.

Part B Eligibility

If you are eligible for Part A, you can enroll in Medicare Part B (Medical Insurance) which has a monthly premium.

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How do I enroll?

You apply for Medicare with the Social Security Administration.

Contact the Social Security Administration in the way most convenient for you.

  • Call Social Security at a toll-free number 1-800-772-1213 to schedule an appointment with your local Social Security office. Appointments can be conducted in person or over the phone.
  • Visit your local Social Security Administration office during normal business hours.
  • Call your local Social Security Administration office to make an appointment.
  • For more information, visit the official Social Security website.

Will I Need To Prove My Age?

You will need to have proof of your age, such as a birth certificate, your previous year’s W-2 form or tax return, and possibly other proof. Call Social Security ahead of time to find out what proof you will need.

When do I enroll?

There are several ways to enroll in Medicare.

  • Automatic Enrollment
  • Initial Enrollment
  • General Enrollment
  • Special Enrollment

Automatic Enrollment

Do you already receive Social Security benefits?

  • If you already receive Social Security benefits, you qualify for Automatic Enrollment. You will automatically receive a Medicare card approximately three months before your 65th birthday.
  • If you receive Social Security Disability benefits, you will automatically get a Medicare card after receiving these benefits for 24 months.

Initial Enrollment

Are You Turning 65 Soon?

  • If you enroll during the three months before your 65th birthday, Medicare becomes effective on the first day of the month you turn 65.
  • If you enroll during the month of your 65th birthday, Medicare becomes effective on the 1st day of the month after your birth month.
  • If you enroll during the three months after your 65th birthday, it will take up to 60 days for your Medicare coverage to start.
  • If you continue to work past age 65, or you are covered by an employer group health plan from your job or a working spouse’s, see Special Enrollment.

General Enrollment

Did You Miss The Initial Enrollment Period?

If you did not enroll during the three months prior to your 65th birthday, the month of your 65th birthday, or the three months after your 65th birthday, you must wait for a General Enrollment period.

The General Enrollment period is January 1 through March 31 of each year. Your Medicare coverage will begin July 1 of that year. You will pay a Part B Late Penalty: 10% surcharge for each year you are late in enrolling. This penalty continues forever. For example, if you enrolled four years late, then you will pay a 40% surcharge for every year that you buy Part B.

Special Enrollment

Are You Covered By An Employer Group Health Plan?

If you continue to work past age 65 and are covered by an employer group health plan or if you are covered under an employer group health plan of an actively working spouse, you can delay enrollment in Medicare without penalty.

Enroll in Medicare Part A when you turn 65 (remember: it is usually free!). When you, or your spouse retires, or your active employment health insurance ends, you have eight months to enroll in Medicare Part B without any penalty. Note: Health plans offered as a retiree benefit are not considered active employment group health plans.

Key points to consider:

  • Most people take Part A because it is premium-free. Even if you delay your Part B, signing up for your Part A when you become eligible makes it simpler whenever you start your Part B.
  • Your employer is key to whether you need Medicare Parts B and D at this time. First, you need a letter from your employer stating whether both your medical coverage and your prescription drug coverage are determined to be “creditable” – as good as Medicare’s.
  • Additionally, you need to ask your employer how your group insurance works with Medicare and whether you are required to buy Part B. (Some employer group plans assume you have Part B and only pay beyond the major part that Medicare would cover.)
  • Once you have this information, you can decide whether you need Part B, Part D, or both at this time. If you plan to delay enrollment in Part B, visit Social Security (not Medicare) to make sure you won’t be penalized later. Document the conversation by writing down the name of the person you spoke with, the date, the time, and what was said.

If you decide to delay enrollment in Part B, your Medicare card explains how to do this. If you delay enrollment in Part B, Part D, or both, you have enrollment deadlines soon after your employer-provided coverage ends.

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What does Medicare cover?

Medicare helps pay for certain health care services and durable medical equipment. To have full Medicare coverage, Medicare beneficiaries must have Part A (Hospital Insurance) and Part B (Medical Insurance).

The following is a partial list of Medicare-covered services. The covered services listed below may require payment of deductibles and copayments.

If you have questions about covered services, call Medicare at 1-800-633-4227.

Part A Coverage

Inpatient Hospital Care

  • Semi-private room and board
  • Special care units, such as intensive care
  • Nursing services
  • Drugs administered by the hospital during the stay
  • Lab tests
  • Radiology services
  • Medical supplies
  • Operating and recovery room costs
  • Rehabilitation services
  • Blood transfusions

Inpatient Skilled Nursing Facility Care

  • Semi-private room and board
  • Nursing services
  • Physical, occupational, and speech therapy services
  • Medical equipment and supplies furnished by the skilled nursing facility during the stay
  • Drugs administered by the skilled nursing facility during the stay

Inpatient psychiatric Care

  • Psychiatric care in a general hospital is treated the same as other inpatient hospital care. (See above)
  • For care in a freestanding psychiatric hospital, Medicare pays for no more than 190 days of inpatient care.

Home Health Care

  • Part-time or intermittent skilled nursing care
  • Physical and speech therapy (limits)
  • Medical social services
  • Medical supplies
  • Durable medical equipment

Hospice Care

  • Doctor and nursing services
  • Home health aide and homemaker services
  • Short term inpatient care
  • Medical supplies
  • Physical, occupational, and speech therapy
  • Drugs (to manage symptoms and pain)
  • Family counseling
  • Medical social services
  • Inpatient respite care (to provide relief for the person who normally provides care--five day maximum stay)

Part B Coverage

  • Physician services received in the doctor’s office, patient’s home, hospital, skilled nursing facility, or anywhere else in the United States
  • Medical and surgical services, including anesthesia (inpatient and outpatient)
  • Radiology and pathology services (inpatient and outpatient)
  • X-rays
  • Medical supplies
  • Blood transfusions (after first three pints)
  • Laboratory tests billed by the hospital
  • Ambulance coverage
  • Drugs and biologicals which cannot be self administered
  • Outpatient hospital services
  • Outpatient physical, occupational, or speech therapy
  • Outpatient maintenance dialysis
  • Community mental health services
  • Comprehensive outpatient rehabilitation services
  • Other services not covered by Part A

Preventative Services

  • Screening mammogram - Medicare will cover a diagnostic mammogram when the doctor has specific reasons for ordering the test or once a year
  • Pap smear and pelvic exam (includes a clinical breast exam) once every two years or once every year if you are high risk
  • Colorectal cancer screening
  • Diabetes monitoring, includes coverage for glucose monitor, test strips, lancets, and self-management training
  • Flu shot once per year
  • Prostate cancer screening for men age 50 and older once every year (Blood test or digital rectal exam)
  • Bone density/osteoporosis screening (if at risk)
  • Pneumonia vaccine - once per lifetime

Services not covered by Medicare

  • Personal convenience items
  • Private duty nurse
  • Private room, unless it is medically necessary
  • Routine physical exams and tests related to exams
  • Routine foot care
  • Dental services
  • Cosmetic surgery
  • Exams for prescribing or fitting eyeglasses or hearing aids
  • Hearing aids or eyeglasses
  • Most immunizations
  • Most chiropractic services
  • Most prescription drugs
  • Custodial care
  • Medical devices not approved by the U.S. Food and Drug Administration
  • Nursery charges
  • Services rendered outside the United States (Canada and Mexico may be exceptions).

If you have questions about covered services, call Medicare at 1-800-633-4227.

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How much does Medicare cost?

Original Medicare

Original Medicare is divided into Part A (Hospital Insurance) and Part B (Medical Insurance).

  • Part A helps pay for inpatient hospital care, some skilled nursing care, home health care and hospice care.
  • Part B helps pay for doctor services, outpatient hospital care, durable medical equipment, home health care not covered by Part A, and other services. Medicare was never intended to pay 100% of medical bills. Its purpose is to help pay a portion of medical expenses. Medicare beneficiaries also pay a portion of their medical expenses, which includes deductibles, copayments, and services not covered by Medicare. The amounts of deductibles and copayments change at the beginning of each year.

Part A - Monthly Premium

If you are eligible, Part A is free because you or your spouse paid Medicare taxes while you were working. You earn Social Security “credits” as you work and pay taxes. For each year that you work, you earn 4 credits.

Credits Earned 2015 Part A Premium
40 or more credits Free
30-39 credits $234/month
up to 29 $407/month

If you do not qualify for premium-free Part A, you may be able to buy it. Contact the Social Security Administration at 1-800-772-1213 for more information.

Part A - Deductibles and Copayments

Hospital Deductible

$1,260 per hospital benefit period for 2015 (A hospital benefit period begins the first day you receive inpatient hospital treatment and continues until you have been out of the hospital or skilled nursing facility for 60 days in a row.)

Hospital Stay Copayment

  • Medicare pays in full (after the hospital deductible of $1,260 in 2015) for days 1-60
  • Medicare pays all but $315 per day for days 61-90
  • Medicare pays all but $630 per day for days 91-150
  • You pay all costs for each day over 150 days

Skilled Nursing Facility Co-Payment

  • You pay nothing for days 1-20
  • You pay $157.50 per day for days 21-100
  • You pay all costs for each day beyond 100 days

Usually, a Medicare Supplement policy will pay for Part A deductibles and copayments.

Part B - Monthly Premium

The Part B premium for 2015 is $104.90 per month for most people. Individuals with income over $85,000 or couples with incomes greater than $170,000 will pay more. Everyone who has Part B pays a monthly premium.

The monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. Beneficiaries enrolled in Part B who do not receive a monthly retirement check are billed by Medicare every three months.

Part B - Deductibles and Copayments

Annual Deductible

  • $147 per year in 2015

Copayments

  • Medicare pays 80% of the Medicare-approved amount. You usually pay 20% of the Medicare-approved amount.
  • You pay all of the limiting charge when a provider does not accept the assignment.

Doctors and other providers who accept assignment agree to accept the Medicare-approved amount for a service. Providers who do not accept assignment may charge you a 15% surcharge. You would be responsible for paying the surcharge (or limiting charge) as well as any copayments.

Therefore, you should always ask a provider to accept the assignment.

For a list of providers in Louisiana who accept assignments, contact 1-800-MEDICARE.

Some Medicare Supplement policies help pay Part B deductibles and copayments.

Should I take Medicare Part B?

You should take Medicare Part A when you are eligible. However, some people may not want to apply for Medicare Part B (Medical Insurance) when they become eligible.

You can delay enrollment in Medicare Part B without penalty if you fit one of the following categories.

  • If you turn 65, continue to work, and are covered by an employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 20 or more employees must offer active workers who are 65 or older the same health benefits provided to younger employees.
  • If you turn 65 and are covered under your working spouse’s employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 20 or more employees must offer spouses of active workers the same health benefits regardless of age or health status.
  • If you are under 65 and receive Medicare due to a disability, you continue to work, and are covered by an employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 100 or more employees must offer disabled workers, who are actively working, the same health benefits provided to other employees.
  • If you are under 65 and receive Medicare due to a disability, and are covered under your working spouse’s employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 100 or more employees must offer the disabled spouses of active workers, the same health benefits given to non-disabled spouses.

Employer group health plans may cover items normally not covered by Medicare Part B. If so, and you meet one of the categories above or below, then you may not need to enroll in Medicare Part B and pay the monthly premium.

If you are:

  • an active worker
  • a spouse of an active worker
  • a disabled, active worker
  • a disabled spouse of an active worker

and choose coverage under the employer group health plan, you can refuse Medicare Part B during the automatic or initial enrollment period. You wait to sign up for Medicare Part B during the special enrollment period, an eight month period that begins the month the group health coverage ends or the month employment ends, whichever comes first.

You will not be enrolling late, so you will not have any penalty.

If you choose coverage under the employer group health plan and are still working, Medicare will be the “secondary payer,” which means the employer plan pays first.

If the employer group health plan does not pay all the patient’s expenses, Medicare may pay the entire balance, a portion, or nothing. An employer group health plan must be primary or nothing.

The employer is NOT allowed to offer Medicare supplemental coverage to people who are actively employed--unless the company has under 20 employees, or if disabled, under 100 employees.

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What are my rights as a Medicare beneficiary?

As a Medicare beneficiary, you have certain guaranteed rights. These rights protect you when you get health care, they assure you access to needed health care services, and protect you against unethical practices.

You have these rights whether you are in Original Medicare, Medigap or Medicare Advantage.

Your rights include, but are not limited to:

The Right to Receive Emergency Care

If you have severe pain, an injury, or a sudden illness that you believe may cause your health serious danger without immediate care, you have the right to receive emergency care. You never need prior approval for emergency care, and you may receive emergency care anywhere in the United States.

The Right to Appeal Decisions About Payments or Services for Medical Care

If you are enrolled in Original Medicare, you have the right to appeal denial of a payment for a service you have been provided. If you are enrolled in another Medicare health plan, you have the right to appeal the plan’s denial for a service to be provided.

The Right to Information About All Treatment Options

You have the right to know about all your health care treatment options from your health care provider. Medicare forbids its health plans from making any rules that would stop a doctor from telling you everything you need to know about your health care. If you think your Medicare health plan may have kept a provider from telling you everything you need to know about your health care options, then you have the right to appeal.

The Right to Know How Your Medicare Health Plan Pays Its Doctors

You must request this information. If you request information on how a Medicare health plan pays its doctors, then the plan must give it to you in writing. You also have a right to know whether your doctor has a financial interest in a health care facility since it could affect the medical advice he or she gives you.

Your other rights include:

  • The right to protection from discrimination in marketing and enrollment practices.
  • The right to information about what is covered and how much you have to pay.
  • The right to choose a women’s health specialist.
  • The right, if you have a complex or serious medical condition, to receive a treatment plan that includes direct access to specialists.
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