Understanding Medicare Basics

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Understanding Medicare Basics
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What Is Medicare?

• A health insurance program for
• People 65 years of age and older
• People under age 65 with certain disabilities
• People with End-Stage Renal Disease (ESRD)
• Administered by Centers for Medicare Medicaid
  Services (CMS)
• Enrollment by Social Security Administration
  (SSA) or Railroad Retirement Board (RRB)

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Different Parts of Medicare

• Medicare has four Parts
• Part A (Hospital Insurance)
• Part B (Medical Insurance)
• Part C (Medicare Advantage)
• Medicare HMO, PPO, PFFSetc.
• Part D (Prescription Drug Coverage)

Original Medicare
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Ways to receive Medicare
Medicare Advantage (HMO, PPO, etc)
Original Medicare
Part B
Part A B
Part A
Part D or Secondary
MedSup or Secondary
Some will include Part D
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Social Security Administration

• Responsible for eligibility and enrollment
• People aged 65 yrs or older
• Contributed into FICA for 40 quarters (10 years)
• Married a minimum of 10 years to receive benefits
  from a former spouse
• Under age 65 yrs
• Receiving disability benefits under SSA or
  Railroad retirement system for 24 months
• Any Age
• Receiving regular dialysis
• Amyotrophic Lateral Sclerosis (ALS)
• a.k.a Lou Gehrigs Disease

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Medicare for Disabled Individuals

• Disability Defined
• Inability to work
• Expected to last for 1 year or result in death
• Can be the result of blindness
• Visual acuity 20/200 or less with correcting lens
  in better eye
• OR
• Visual field of 20 degrees or less
• Note SSA is responsible for disability
  determination

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Qualifying for Disability Benefits

• Meet requirements
• Definition of disability
• Work credits
• Or relationship to someone with work credits
• 5-month waiting period
• Exceptions
• People eligible for childhood disability benefits
• Some people previously entitled to disability
  benefits

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Applying for Disability Benefits

• Call SSA at 800-772-1213
• Necessary documentation needed
• Social Security Number
• Proof of age
• Health-care provider information
• Medical records
• Work history
• including W-2 for the past two years
• But dont wait to apply

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Qualifying for Medicare

• 24-month waiting period
• Exception for people with ALS
• No additional waiting period
• Medicare starts with first month of benefits
• Medicare usually begins 30th month after
  disability began
• 5 months 24 months 29-month wait

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Enrolling in Medicare

• Automatic enrollment in Original Medicare
• After 24 months of disability entitlement
• Except for ALS
• Will receive card by mail
• Call Social Security if it doesnt arrive
• Decide whether to keep or decline Part B
• Decide about enrolling in Part D

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ESRD Disability For Medicare

• Coverage begins
• Fourth month of dialysis
• First month if certain conditions are met
• Month you receive a kidney transplant
• Month you are admitted to approved hospital
• For transplant or procedures preliminary to
  transplant
• 2 months before month of transplant
• If transplant is delayed more than 2 months

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The Original Medicare Plan

• Go to any provider that accepts Medicare
• Part A
• Premium free for most people
• Others may be able to purchase
• If a U.S. citizen
• Legal U.S. resident of 5 continuous years or more
• Part B
• You pay monthly premium
• Starting in 2007 some individuals have their
  premiums based on their taxable income
• Pay part A and Part B
• Deductible
• Coinsurance or copayment

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Your Medicare Card (front)
Jane Doe
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Medicare Part A Covered Benefits

• Hospital Stays
• Semi-private room and board, general nursing,
  meals, and other hospital services and supplies
• Skilled Nursing Facility Care
• Inpatient skilled nursing or rehabilitative
  services
• Custodial Care not covered
• Home Health Care
• Part-time skilled nursing care, home health aids,
  physical and occupational therapy, speech and
  language pathology
• Hospice Care
• For people with a terminal illness
• Includes drugs for symptom control and pain relief

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Medicare Part B Covered Benefits

• Medical Expenses
• Physicians services, some diagnostic test,
  physical and speech therapy, ambulance, etc.
• Home Health Care
• Part-time skilled nursing care, home health aids,
  physical and occupational therapy, speech and
  language pathology
• Outpatient Hospital Services
• Outpatient surgery, diagnostic procedures,
  emergency room, etc.
• Durable Medical Equipment
• Walkers, wheel chairs, hospital beds, etc.

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Medicare Part B Covered Benefits

• Preventative Services
• Welcome to Medicare Physical Exam within 12
  months of entitlement to Part B

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Services NOT Covered

• Part A
• Hospitalization beyond 150 days
• Custodial Services
• Skilled Nursing Facility beyond 100 days
• Full-time nursing care at home
• Part B
• Most routine physical exams
• Most routine foot care
• Dental care
• Acupuncture
• Eye and hearing exams

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Medicare Part B Premium

• Monthly Medicare Part B premium in 2010
• Most people pay 96.40
• Programs available to help

Premium higher for new enrollees in 2010 people
who do NOT have premiums withheld from SSA
benefit including those who qualify for
Medicare/Medicaid and have Part B premium paid by
Medicaid.
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Paying the Part B Premium

• Taken out of your monthly payment
• Social Security
• Railroad Retirement
• Federal Government retirement
• For information about premiums
• Call SSA or RRB
• Office of Personnel Management if a retired
  Federal employee
• Will be billed every 3 months
• If not receiving SSA or RRB benefits
• Medicare Easy Pay