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What Seniors and Baby Boomers Need to Know About Medicare

Senior Journal, October 28, 2002

Medicare is a critical government service helping provide healthcare for senior citizens and certain disabled U.S. citizens. Some of the service is free, after deductibles, but others cost minimal amounts. It does not provide total healthcare coverage, as some assume. And, it does not cover dental care.

The free Medicare service available to all U.S. seniors at age 65 is called Medicare Part A, and it is helps with hospital costs. Medicare Part B requires a monthly fee and it helps pay for medical costs. More specifics are included in the table at the end of this article.

Medicare has an excellent Website at http://www.medicare.gov/, which is easy to use. We highly recommend you use this site for updated information on Medicare. Here, however, we have provided some of the basic information in a quick to read format.

Medicare Has Two Parts. They are:

· hospital insurance or Medicare Part A (hospital insurance), which helps pay for care in a hospital and skilled nursing facility, home health care and hospice care; and

· medical insurance or Medicare Part B (medical insurance), which helps pay for doctors, outpatient hospital care and other medical services.

Most people do not have to pay for Medicare Part A. And, if you receive Social Security, you will be automatically enrolled for Part A the month before your 65th birthday.

The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can visit their web site at www.ssa.gov.

If you (or your spouse) did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A.

If you are under age 65, you can get Part A without having to pay premiums if:

· You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (Note: starting July 1, 2001, if you have Lou Gehrig's disease, you can get your Medicare benefits either July 1, 2001 or the first month you get disability benefits, whichever is later.)

· You are a kidney dialysis or kidney transplant patient.

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. The monthly Part B premium in 2002 is $54.00 and in 2003 will be $58.70. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.

Most people sign up for and buy Medicare Part B. If you want to join a Medicare managed care plan or a Medicare Private Fee-for-Service plan, you will need to have both Medicare Parts A and B.

You may want to wait to sign up for Medicare Part B if you or your spouse are working and have health coverage through you or your spouse's employer or union. (See note below if you work for a small company.) You would have to pay the monthly Medicare Part B premium, and the Medicare Part B benefits may be of limited value to you as long as the group health plan is the primary payer of your medical bills.

Note: If you are working for a small company (less than 20 employees), you should talk to your employee health benefits administrator before making any decision not to take Medicare Part B. If your employer has less than 20 employees, Medicare is the primary payer and your group health insurance would be the secondary payer.

You may also wish to read : Medicare and Other Health Benefits: Your Guide to Who Pays First

If you want assistance in finding a private Medicare + Choice plan (HMO) to meet your specific needs, go to this Medicare site:

Medicare Personal Plan Finder

http://www.medicare.gov/MPPF/home.asp

If you don’t take Medicare Part B when you are first eligible because you or your spouse are working and have group health plan coverage through your or your spouse’s employer or union, you can sign up for Medicare Part B during a Special Enrollment Period.

Specific Medicare Coverage

Medicare Part A Coverage

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care. You must meet certain conditions.

Medicare Part A Helps Cover Your:

Hospital Stays: Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental health care. This does not include private duty nursing, or a television or telephone in your room. It also does not include a private room, unless medically necessary. Read Medicare and Your Mental Health Benefits for more information on inpatient mental health benefits.

Skilled Nursing Facility Care: Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day hospital stay). Read Medicare Coverage of Skilled Nursing Facility Care for more information.

Home Health Care: Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Read Medicare and Home Health Care for more information.

Hospice Care: Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in your home. However, short-term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed.

Blood: Pints of blood you get at a hospital or skilled nursing facility during a covered stay.

Medicare Part B

Medicare Part B (Medical Insurance) helps cover your doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare Part B premium of $54.00 per month in 2002.

New - 2003 Medicare Premium and Deductible Rates

Medicare Part B Helps Cover Your:

Medical and Other Services: Doctors' services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Also covers second surgical opinions, outpatient mental health care, outpatient physical and occupational therapy, including speech-language therapy. Read Medicare and Your Mental Health Benefits and Getting a Second Opinion Before Surgery for more information.

Clinical Laboratory Services: Blood tests, urinalysis, and more.

Outpatient Hospital Services: Hospital services and supplies received as an outpatient as part of a doctor's care.

Blood: Pints of blood you get as an outpatient or as part of a Part B covered service.

Medicare Also Helps Cover:

· Ambulance services (when other transportation would endanger your health).

· Artificial eyes.

· Artificial limbs that are prosthetic devices, and their replacement parts.

· Braces - arm, leg, back, and neck.

· Chiropractic services (limited), for manipulation of the spine to correct a subluxation.

· Emergency care.

· Eyeglasses - one pair of standard frames after cataract surgery with an intraocular lens.

· Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare).

· Kidney dialysis. Read Medicare Coverage of Kidney Dialysis and Kidney Transplant Services for more information.

· Macular degeneration of the eye ("wet" age-related) treatment, using ocular photodynamic therapy with verteporfin.

· Medical nutrition therapy services for people with diabetes or kidney disease with a doctor's referral.

· Medical supplies - items such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies.

· Outpatient prescription drugs (very limited). For example, some oral drugs for cancer.

· Preventive services. Read Medicare Preventive Services to Keep You Healthy or Women with Medicare - Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam for more information.

· Prosthetic devices, including breast prosthesis after mastectomy.

· Second opinion by a doctor (in some cases). Read Getting a Second Opinion Before Surgery for more information.

· Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners.

· Telemedicine services in some rural areas.

· Therapeutic shoes for people with diabetes (in some cases).

· Transplants - heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions and when performed at approved facilities).

· X-rays, MRIs, CAT scans, EKGs, and some other diagnostic tests.

What is not paid for by Medicare Part A and Part B:

The Original Medicare Plan does not cover everything. Health care costs not covered by Medicare will include, but are not limited to:

· Acupuncture.

· Deductibles, coinsurance, or copayments when you get health care services.

· Dental care and dentures (in most cases).

· Cosmetic surgery.

· Custodial care (help with bathing, dressing, using the bathroom,and eating) at home or in a nursing home.

· Health care you get while traveling outside of the United States (except in limited cases).

· Hearing aids and hearing exams.

· Orthopedic shoes.

· Outpatient prescription drugs (with only a few exceptions).

· Routine foot care (with only a few exceptions).

· Routine eye care and most eyeglasses (see exception above for one pair of standard frames after cataract surgery with an introcular lens).

· Routine or yearly physical exams.

· Screening tests except those listed in Medicare Preventive Services to Keep You Healthy.

· Shots (vaccinations) except those listed in Medicare Preventive Services to Keep You Healthy.

Medicare + Choice plans (like an HMO) may include extra benefits such as prescription drugs, dental care, routine physical and vision services. You can learn more about whether Medicare + Choice plans are available in your area and any extra benefits offered by these plans by visiting Medicare Health Plan Compare. Please visit the Your Medicare Coverage section of Medicare's Website for expanded information regarding your current Medicare Part A and Part B coverage under the Original Medicare Plan.

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