MEDICARE - PART A AND PART B
  
TOPICS
  1. INTRODUCTION
  2. ENROLLING IN MEDICARE
  3. HELP DECIDING – WHERE TO FIND HELP
  4. WHAT IS COVERED UNDER MEDICARE - HOSPITAL BILLS AND DOCTOR BILLS
     

    MEDICARE PART A –INFORMATION
     

    Medicare Part A - Hospital Benefits Covered/Provided
     

    Medicare Part A – Skilled Nursing Home Rehab Services
     

    MEDICARE PART B – INFORMATION
  5. MEDIGAP INSURANCE
  6. OTHER MEDICARE PROGRAMS
 
INTRODUCTION  

Medicare Part A and Part B are a health insurance programs of the federal government designed to cover those over the age of 65, blind, or disabled (persons who have been determined by social security to be “disabled” and on social security disability – SSDI for at least twenty four (24) months).

Think of Medicare as health insurance for retirees and the disabled who have worked and reported income via social security for a defined number of years (Generally to receive the maximum benefits offered one must have worked and reported wages to Social Security for 10 years). For an additional premium, persons who worked in the United States for less than 30 quarter sin a lifetime can purchase coverage under Part A and Part B.

NOTE: Medicaid is a program designed for those with assets and income below a certain levels. It IS NOT health insurance nor associated with Medicare health insurance.

PART A - If a person worked the required 40 quarters hours in a lifetime (10years), he/she will receive Medicare Part A (Hospital coverage) at no additional premium. Co-Pays and Deductibles will still apply. (See “What is covered under Medicare “ section of this outline for more details).
PART B – Is health insurance to pay for doctors, lab tests, and physical therapy. This coverage is voluntary. You do not have to buy it. There is a reduced premium of $88.50 a person pays to have this coverage. There are deductibles and co-pays as well. (See “What is covered under Medicare “ section of this outline for more details).

  
 
ENROLLING IN MEDICARE PART A AND PART B  
There are three types of health insurance models for each new Medicare enrollee to choose from.

When you sign up for Medicare you have a choice of three insurance models (Choose one):

1. Traditional Fee-for-Service Medicare – Similar to the old Blue Cross Blue Shield health insurance we all knew back in the 1960’s. You go to any doctor who is on the Medicare provider list. You pay a monthly premium ($88.50 in 2005) a deductible and a co-pays of 20%.
2. Managed Care Medicare (HMO) - Medicare C – now called Medicare Advantage. These plans are designed where there is a “gatekeeper physician” assigned to monitor and define your care and what specialist you need to see. You must get referred by the “gatekeeper physician” before you can see a specialist. Small co-pays of around $5.00 applies on each visit.
3. Private Fee for Service Plans – New Medicare insurance offered by private insurance groups who provide you all the Medicare services. It is like a privately run HMO where the physicians and services are limited to those offered by that private insurance groups list of providers. Check with the county Medicare office where you live to get a list of private insurance providers.
  
 
HELP DECIDING – WHERE TO FIND HELP  
You can get help in making a decision on what type of Medicare Plan is best for you. There are several to choose from. Go to the Medicare website at www.Medicare.Gov and choose “Medicare Personal Plan Finder”. This will walk you through key decision questions on what plan is best for you. You can also call 800-633-4227.

You must file an application to enroll in Medicare Part B. It is not automatic. Three months prior to your 65th birthday the Social Security Administration will send you an application to enroll in Medicare.

The enrollment window is a total of seven (7) months. Three months before your 65th birthday, the month of your birthday, plus three months after the month of your birthday.

If you miss enrollment you must wait until the next general enrollment period for Medicare (January 1 to March 31 of each year) with coverage starting in July of the year you enroll.

NOTE: If you do not enroll on your 65th birthday and are not covered by an employer or former employer during that period, your premium will increase by ten percent (10%) for each year you were not enrolled or covered by another plan.

  
 
WHAT IS COVERED UNDER MEDICARE - HOSPITAL BILLS AND DOCTOR BILLS  
Medicare program consists of two primary parts. Medicare Part A and Medicare Part B.
  
 
MEDICARE PART A –INFORMATION  
Medicare Part A – pays for the first ninety (90) days of a hospital stay, limited home healthcare, hospice, and skilled nursing facility care when admitted for rehab and covers Nursing home provided meals, a semi-private room, nursing home skilled rehab services (for up to 100 days maximum – Patient pays a co-pay from days 21-100).

To qualify for Medicare Nursing Home Skilled Rehab benefits - a patient must have had a hospital stay of at least three nights within thirty days prior to being admitted into the nursing home for rehabilitation. The rehab stay must be related to the illness for which the hospital stay was necessary.

No premium is required for Medicare Part A coverage as of the 2006 program year if you worked and paid into the social security system for ten (10) work years or more. That is forty (40) quarters of work and it does not have to be continuous. Under Medicare Part A there are applicable co-pays and deductibles.

One can purchase a “Supplemental Insurance Policy” to cover paying Medicare co-pays and deductibles. This is called Medigap insurance.
For useful information on choosing a Medigap policy go to the Medicare website at http://www.medicare.gov/Publications/Pubs/pdf/11080.pdf

  
 
Medicare Part A - Hospital Benefits Covered/Provided  
Hospital Benefits coverage period = “Spell of illness”. Each patient is entitled to a total of ninety (90) days (does not have to be continuous consecutive days of covered services) of Medicare Part A services. This coverage period starts from the first date of admittance into a hospital. The coverage period will end sixty (60) days after the last day the patient receives in-patient services or extended care services related to the hospital stay.

A person has an unlimited number of “spells of illness” in a lifetime. Basically a person must wait sixty (60) days after a hospital/nursing home rehab related services ends to have an additional ninety (90) days of Medicare Part A benefits period start again.
Each person has an additional sixty (60) lifetime reserve days of Medicare Part A hospital stay coverage if a stay extends beyond the ninety (90) days.

NOTE: Medicare does NOT cover the first three (3) pints of blood a patient receives while in the hospital

Medicare Part A – In-Patient Hospital Stay - Deductibles and Co-Pays

Medicare pays 100% of the first sixty (60) days after the patient pays the deductible ($952.00 in 2006).

Days 61-90 the patient must pay a co-insurance amount of 25% of the deductible per day ($238.00 per day in 2006)

Co-Insurance, if the patient elects to use some of his/her 60 lifetime reserve days (for days 91-150), he/she must pay a co-insurance amount equal to fifty percent (50%) of the deductible for each lifetime reserve day they use ($476 per day in 2006).

  
 
Medicare Part A – Skilled Nursing Home Rehab Services  
The patients attending physician in the hospital must prescribe skilled rehabilitation in order to qualify for this benefit. The physician “discharge plan” prescription and physician’s directions are the primary driver of eligibility for this Medicare Part A benefit.

Eligibility – As outlined above, the patient’s doctor for the hospital stay must prescribe skilled rehabilitative services for the patient and the patient must have had a stay lasting at least three (3) nights (discharge on fourth day) in the hospital within thirty (30) days of being admitted for skilled nursing rehab. The rehab must be directly related to the reason for the hospital stay.

Covered Services – The first twenty (20) days in the skilled rehab facility will be covered, provided the rehabilitation services are given at least five days per week and the rehabilitation is helping the patient at least “maintain a level he/she has attained in the rehabilitation. Days 21-100 there is a co-pay, which is $119.00 per day in 2006.

Many facilities have a misconception that the patient no longer qualifies if he/she “plateaus” in his/her rehabilitation. If this occurs it is imperative you contact the attending physician and get this resolved or contact the Ombudsman for the Medicare provider you have to appeal such a decision. Contact:

  • Florida Quality Improvement 800-844-0795
  • Long term Care Ombudsman at 888-831-0404.

See also Medicare’s website publication HCFA-10119 on Medicare Appeals and Grievances procedures at www.Medicare.Gov

  
 
MEDICARE PART B – INFORMATION  
Eligibility Medicare Part B – This is medical insurance to pay for doctors and medical tests, etc). It is a voluntary participation program.

It is synonymous with Medical Health Insurance for those over 65 and those qualified as disabled under Social Security laws.

It pays for covered doctor visits, some home healthcare, medical equipment, certain outpatient hospital care, physical therapy, lab tests, diagnostic testing.

Monthly Insurance premium $88.50 in 2006 for those who worked at least 10 years (40 quarters)

Deductible - $124.00/year in 2006

  
 
MEDIGAP INSURANCE  
This is additional insurance only available to persons on Traditional Medicare Part A and Part B.

Medigap insurance can purchase from a private insurance company to cover “gaps” in Medicare coverage (i.e. Co-Insurance, deductibles and co-pays). Thus the term “Medigap” health insurance policy.

The federal government has allowed private insurance companies to sell standardized plans. Go to

For useful information on choosing a Medigap policy go to the Medicare website at http://www.medicare.gov/Publications/Pubs/pdf/11080.pdf

New enrollees have an open enrollment period of six months after turning age 65 and enrolled in Medicare Part B in which to decide if he/she wants to purchase a Medigap policy. During this period the insurance providers cannot deny you coverage for their supplemental Medigap insurance products. It is difficult to enroll after this open enrollment period. So it is suggested you enroll during the initial enrollment period or you might not be able to purchase that policy later.

There are Plans A through J as well as Medicare Select (HMO type Medigap coverage). Plan C is most affordable coverage which also covers Medicare Part A and Part B Deductible and the Skilled Nursing Rehab Co-Insurance covering the 100 days of skilled rehab services. Most people find Medicare Select, Medigap A, B, or C are the most affordable for them.

No Medigap insurance policies should be offering prescription drug coverage after January 2006. If you have a Medigap insurance policy offering such coverage, contact the provider immediately to see if you have what is referred to as “creditable prescription drug coverage”. If you do not you should consider purchase of a Medicare Part D Prescription Drug Plan.

  
 
OTHER MEDICARE PROGRAMS  
In 2006 the new Medicare Part D, which is the Prescription Drug discount program. (LINK TO THIS WEBSITES PART D OUTLINE

Other Medicare Programs include Medicare Part C – Now called MEDICARE ADVANTAGE (A Managed Care – HMO health care Medicare insurance. It provides the same services covered under Medicare Part A and Part B coverage accept in an HMO).

In 2006 the new Medicare Part D, which is the Prescription Drug discount program.

For more information of these programs and details contact Medicare at 800-772-1213. Medicare’s website is an excellent resource as well www.Medicare.Gov