MEDIMASTER GUIDE MediMaster Guide 25
Appendix: MediMaster Guide MEDICARE What is Medicare? Medicare is a hospital insurance program in the U.S. that pays for inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. Who is eligible for Medicare People 65 and older and eligible to receive Social Security Most eligible people are automatically enrolled at age 65 Certain people younger than 65, permanently disabled, and having received Social Security disability insurance payments for at least two years People on continuing dialysis for permanent kidney failure or who need a kidney transplant People who have Amyotrophic Sclerosis ( ALS Lou Gehrig s disease ) How much does Medicare Part A cost? Most people pay nothing because they paid Medicare taxes while working You may be able to buy Part A if you aren t entitled to it Your state may help you pay for Part A if you have limited income and resources What services does Medicare Part A Cover? Semiprivate room and meals in a hospital (up to a set limit) General nursing Other hospital services and supplies Medicare Part A Does Not Cover: Private duty nursing In-room televisions or telephones Private rooms, unless medically necessary Skilled Nursing Facility Care: (following a related 3 day inpatient stay, up to a set limit) Semiprivate room and meals Skilled nursing and rehabilitative services Other services and supplies Home Healthcare: Limited to reasonable and necessary part-time or intermittent skilled nursing care 26
Home health aide services Physical therapy Occupational therapy Speech language pathology Medical social services Durable medical equipment, including wheelchairs, hospital beds, oxygen, and walkers Medical supplies and other services Hospice Care for people with a terminal illness: Drugs and other treatments to relieve pain or other symptoms such as difficulty breathing Medical, nursing and social support services from a Medicare-approved hospice Other services not otherwise covered by Medicare, including grief counseling and pastoral care Respite care Blood: Pints of blood received at a hospital or skilled nursing facility What is Medicare Part B? Medicare Part B is medical insurance that helps pay for doctor s services, outpatient hospital care, durable medical equipment and some medical services that aren t covered by Medicare Part A Who is eligible for Medicare Part B? Anyone who is 65 years old, a U.S. citizen or a legal resident of at least five consecutive years is eligible to enroll in Medicare Part B How much does Medicare Part B cost? You pay the Medicare Part B premium each month You also pay a deductible before Medicare starts to pay its share The Part B deductible and premium rates may change every year in January You may be eligible for financial assistance from Medicaid to pay your Part B premium and deductible You must sign up during the seven month period that begins three months before you turn 65 or you may have to pay an extra 10% for the rest of your life. What does Medicare Part B cover? Medical and other services: Doctors service, but not routine exams except for a Welcome to Medicare 27
one time physical exam within the first six months you have part B Outpatient medical and surgical services and supplies Diagnostic tests Ambulatory surgery fees for approved procedures Durable medical equipment, including wheelchairs, hospital beds, oxygen, and walkers A second and sometimes a third surgical opinion for non-emergency surgery Outpatient mental healthcare Outpatient occupational and physical therapy, including speechlanguage pathology Clinical laboratory services: Blood services Urinalysis Some screening tests and more Home health care: Reasonable and necessary part-time or intermittent nursing care and home health aide services Physical therapy, occupational therapy, and speech-language pathology ordered by doctor When skilled nursing care or therapy are being provided, home health aid services may also be covered if needed Medical social services Durable medical equipment, including wheelchairs, hospital beds, oxygen, and walkers Medical supplies and other services Outpatient Services: Hospital services and supplies received as an outpatient under a doctor s care Blood: Pints of blood received as an outpatient or as a part of Part B-covered service Medicare Part C What is Medicare Part C? Also known as Medicare+Choice and Medicare Advantage, it offers expanded benefits for a fee through private health insurance programs such as health maintenance organizations HMO s and preferred providers organizations PPO s that have contracts with Medicare. 28
You need to have Part A and Part B to qualify for Part C. In most states if you sign up for Part C the month you turn 65 or within a six-month window after your 65th birthday you will qualify without having to answer medical questions. If you do not sign up during the enrollment period, you will have to answer a medical questionnaire and can be turned down for health reasons. Medigap What is Medigap? Medigap is a health insurance option that can be purchased from a private insurance company to fill in the gaps in Medicare Part A and Part B. There are 10 standardized Medigap plans. Each offers different benefits Medigap and Part C premiums vary widely and benefits are the same. Part D What is Medicare Part D? A voluntary outpatient prescription drug benefit for people eligible for Medicare Replaces Medicaid as the primary source of drug coverage for low-income and disabled people who are dual eligibles or people with both Medicare and Medicaid Assistance with drug benefit premiums and cost sharing is available for beneficiaries with low incomes and modest assets Benefit offered through two types of private plans: Stand alone prescription drug plans PDP s Medicare Advantage prescription drug plans MA-PD s through HMO s or PPO s Premiums vary and include initial 25% co-payment Every year a person pays for the first $3,850 of medication expenses. After that, Medicare Part D pays 95% of total medication costs. Your Medicare Rights Medicare participants have a right to appeal or question decisions made about health care payment or decisions. An appeal may be made if: A service or item you got isn t covered, and you think it should be. A service or item is denied, and you think it should be paid. You question the amount Medicare paid Choosing Medicare Benefits Participants in Medicare may choose different ways to get services. When you are first eligible for Medicare, you will make your choice. Each year you can review your health and prescription needs and change to a different plan during the enrollment period. Careful consideration of these options is important. Be sure to consider: 29
Cost What do you have to pay out-of-pocket, including premiums (amount you must pay for insurance)? Benefits Are extra benefits and services, like eye exams or hearing aids covered? Doctor and Hospital choice Can you see the doctor you want? Can you go to the hospital you want? Convenience Where are the doctors offices? Prescription drugs What will your prescription drugs cost under that plan? Pharmacy choice What pharmacies can you use? Quality of care Will you have the best possible health care available? MEDICAID Medicaid is a federally-funded, state-run program that provides medical assistance for individuals and families with limited incomes and resources. Medicaid benefits vary from state to state. Medicaid does not pay money, instead it sends payments directly to health care providers. In some states a small part of the cost called a co-payment must also be paid by the insured. In Texas, health care costs, including doctor s visits and eye care are covered for the following categories of people: persons who have children and a limited income persons who receive or are eligible for Supplemental Security Income ( SSI ) a pregnant woman who meets income requirements a family whose assets are less than $2,000 a person who receives adoption assistance or foster care assistance Medicaid Services include: Inpatient hospital services Outpatient hospital services Prenatal care (care for pregnant women) Vaccines for children Physician services Nursing facility services for persons aged 21 or older Family planning services and supplies Rural health clinic services Home health care for persons eligible for skilled-nursing service Laboratory and x-ray services Pediatric and family nurse practitioner services Nurse-midwife services Early periodic screening, diagnostic, and treatment services for children under age 21 30
Medicaid Eligibility Determining Factors *Note some eligibility rules vary from state to state U. S. Citizen Resident Alien Supplemental Security Income (SSI) Infants and children Pregnant women Aged Blind and Disabled Disabled Must be a disabling condition or impairment that has already lasted 1 year or is expected to last for at least one year Physical disabilities Brain or spinal cord injury Blindness * Mental Disabilities Severe mental or emotional illness such as Alzheimer s Disease Other Disabling conditions Cerebral Palsy Cystic Fibrosis Downs Syndrome Mental Retardation Muscular Dystrophy Autism Spina Bifida HIV/AIDS Low Income and assets requirements Certain Medicare recipients Dual eligibility qualify for Medicare and Medicaid Qualified Medicare Beneficiaries Specified Low-Income Medicare Beneficiaries Qualified Disabled and Working Individuals Foster care children and adopted children under *Title IV-E Financial assistance grant program Your Medicaid Rights You have the right to a Medicaid Fair Hearing if you are denied or if a service requiring prior authorization is denied or modified. You can bring a friend, family member, advocate, or attorney to help you with your appeal 31