What Medicare Covers
Under Medicare Part A
You Pay: Premium Nothing (if you have worked for 10 years or more) Inpatient Hospital $776 deductible No coinsurance for days 1-60 $194 daily coinsurance for days 61-90 $388 daily coinsurance for 60 lifetime reservdays Skilled Nursing Facility No deductible for each benefit period No coinsurance for days 1-20 $97 daily coinsurance 21-100 Home Health Care No deductible or coinsurance Hospice Care No deductible Small copayment for outpatient drugs and inpatient respite care
Under Medicare Part B
Service: You Pay: Doctor and other medical services 20% Outpatient hospital care 20% Ambulatory surgical services 20% Home health care Nothing Clinical diagnostic lab services Nothing Other lab tests and x-rays 20% Diabetes self-management supplies (Glucose monitors, lancets, test strips) 20% Durable medical equipment (wheelchairs, hospital beds, etc.) 20% Physical therapy services 20% Ambulance services 20% Chiropractor Services 20% Outpatient mental health services 50%
Medicare does not cover these services. You must pay the full cost yourself:
· private duty nursing
· most prescription drugs
· custodial care, if skilled care is provided at the same time
· most chiropractic services
· cosmetic surgery
· care outside of the United States
· eyeglasses, except after cataract surgery
· dental care
It is important to think about how you get your health care from Medicare. If you do nothing, you will automatically get Original Medicare.
Your Medicare plan choices are Original Medicare, Original Medicare with supplemental coverage, and sometimes a Medicare HMO.
What is Original Medicare?
Under Original Medicare (also known as traditional Medicare), the government pays directly for your health care each time you get care. You can use almost any doctor and hospital in the United States.
What is Medicare Supplemental Coverage?
Supplemental coverage pays for some things that Medicare doesn't cover, like deductibles, doctor and hospital coinsurance and emergency care outside the U.S. You can get it from private companies like AARP. You can sometimes get even better supplemental coverage from a former job. And, if your income is low, you can sometimes get free coverage from Medicaid and other government programs.
What is a Medicare HMO?
A Medicare HMO is a private health plan that has a contract with the federal government to provide you with health care. Generally, you can only use doctors and hospitals that are part of the HMO, but you may get some extra benefits such as prescription drugs and eyeglasses.
Three Things You Should Know
1. No matter which Medicare choice you make, as long as you have Parts A and B, you have the right to at least the same basic benefits. But your Medicare plan will decide how much care you need and when you need it.
2. Before you sign up for a Medicare plan, make sure you know what you are signing up for. Don't sign anything right away. Give yourself time to think about it and look into it further.
3. If you do not get the care you think you need under Medicare, don't take no for an answer. Appeal the decision.
Original Medicare is the traditional fee-for-service program offered by the federal government. The government pays for part of each service you get. You are automatically enrolled in Original Medicare once you sign up for Medicare.
If you want to stay with Original Medicare, you do not have to do anything.
You can use almost any doctor or hospital in the country and get care when you think you need it.
Unless you have supplemental coverage, you will have to pay a large hospital deductible, a $100 annual deductible for doctor visits, and 20% of the cost of most outpatient medical care.
Original Medicare does not cover prescription drugs, routine dental care, hearing aids, vision care, routine foot care, or long-term care.
Original Medicare with Supplemental Coverage
Supplemental coverage helps fill gaps in Original Medicare.
Private companies offer supplemental coverage, often called “Medigap” plans, with the following basic benefits:
- hospital coinsurance coverage
- 365 days of full hospital coverage
- the 20% of the cost of your medical care that Medicare does not cover
- the first 3 pints of blood you need each year
Depending on which Medigap plan you choose, you may get these extra benefits as well:
- hospital deductible
- limited prescription drug coverage
There are ten different Medigap plans, labeled A-J. Plan A offers the fewest benefits and is the least expensive; Plan J offers the most benefits and is the most expensive. Your State Department of Insurance can give you a list of companies that sell Medigap in your state. You can also call your State Health Insurance Assistance Program or the Medicare hotline (1-800-MEDICARE) for free Medicare help.
Health coverage from a former job, often called “retiree” coverage, generally gives you better coverage than a Medigap plan. You should think carefully before giving it up because it can be hard to get back.
If your income and assets are low, you may be able to get free supplemental coverage from Medicaid or other government programs.
Medicare HMOs are run by private companies that are paid by the federal government to provide health care. You must have both Medicare Part A and Part B to enroll in a Medicare HMO. However, a Medicare HMO may not be available in your county, so you may not have this choice.
Unlike Original Medicare, a Medicare HMO will only let you see certain doctors or hospitals within your area unless you have an emergency. These doctors and hospitals are part of what is called the HMO’s network. You must choose a primary care doctor from the network. That doctor decides when you can see a specialist.
A Medicare HMO will cover most Medicare-covered costs, except for small fees, as long as you use the HMO’s doctors and follow HMO rules.
Medicare HMOs must cover the same kinds of care that Original Medicare covers, but they decide when you need it. They may also offer other benefits like:
- limited prescription drug coverage
- hearing aids
- physical exams
Four Things You Should Know
About Medicare HMOs
1. Don't assume that because a benefit is listed in a Medicare HMO brochure that you will get it when you want it. Medicare HMOs decide how much care you need and when you need it.
2. If you want to keep seeing your current doctors, call them to make sure they are in the HMO network and are taking new HMO patients.
3. Before joining a Medicare HMO, ask if it will cover the medications you currently take. Many Medicare HMOs will cover only specific drugs on their lists.
4. Stay on top of changes in your coverage every year. Medicare HMO doctors and hospitals can leave the HMO at any time, and HMOs can raise premiums, cut their benefits, or end their Medicare contracts each year. Changes are usually announced in September and take effect the following January.
Key Points about Your Choices
If you're happy with your current Medicare coverage, you can keep it without doing anything.
You will be signed up automatically for Original Medicare when you first get Medicare, unless you sign up for a Medicare HMO.
You can switch Medicare plans whenever you want through December 2001.
Get free, reliable information from your State Health Insurance Assistance Program in addition to information from health plans and their sales agents.
Original Medicare is available everywhere. Medicare HMOs may not be available in your area.
Choosing a Medicare Plan
If you want to keep seeing the same doctor...
If you have a regular doctor that you want to keep seeing, you can use Original Medicare with no problem.
If you want to join a Medicare HMO, find out which Medicare HMO plans, if any, your doctor is in.
If you see more than one doctor...
With Original Medicare, you can see a specialist whenever you want. The specialist decides whether care is necessary and, if it is, Medicare usually pays for it.
Medicare HMOs generally will not pay for care from a specialist unless you have a referral from your primary care doctor and the specialist is in the HMO. Sometimes, the HMO may not give the specialist permission to provide care even if the specialist thinks you need it.
If you travel frequently...
With Original Medicare, you can see any doctor anywhere in the country. If you move or travel within the United States, you do not have to worry about your health care coverage.
A Medicare HMO usually does not cover your care outside your community except in emergencies or if you need urgent care.
Some HMOs may cover your care away from home. Check with the HMO to find out its rules.
Questions to Ask Before you Choose
The right Medicare plan depends on how much money you have to spend and what kinds of health care services are most important to you. Before choosing between Original Medicare and a Medicare HMO, find out the answers to these four questions:
1. Which doctors will you be able to see? Can you see the doctors you want to see?
2. Will you have prescription drug coverage? How much coverage will you have?
3. Will the Medicare plan pay for your care when you travel or are away from home?
4. If you also have Medicaid, you may have the best benefits with the least expensive coverage with Original Medicare. How will your new plan work with Medicaid?
Remember, just as some doctors are better than other doctors, some Medicare plans are better than others. Get reliable information from people you trust before you make your decision.
Using Your Medicare Plan
If you have Original Medicare...
When you see your doctors, ask if they accept assignment for Medicare claims. If your doctors accept assignment, they accept the amount Medicare approves as payment in full. Medicare usually pays 80% of that amount, and you or your Medigap plan pays 20%.
If your doctors do not accept assignment, they can charge you up to 15% over the amount Medicare approves under federal law. Some states limit doctors charges even more. Check with your SHIP for the rules in your state.
You should show your Medicare card whenever you get medical care. This will assure that your doctor sends in a claim to Medicare for payment. Make sure you give your exact name and claim number.
If you lose your card, contact the Social Security Administration right away. You can get the phone number and address of your local Social Security office by calling 1-800-772-1213.
If you are in a Medicare HMO...
If you are enrolled in a Medicare HMO, you should show your HMO card instead of your red, white, and blue Medicare card whenever you get care. The HMO, not Medicare, will pay your doctors and other providers if you are enrolled in an HMO.
In a Medicare HMO, you must have a primary care doctor who handles your basic health care. You should choose a doctor who belongs to the HMO as soon as you enroll.
If you want to see a specialist, you must generally get a written referral--the doctor's OK--from your primary care doctor. If you see a specialist without a referral, you usually must pay the entire cost of the visit to the specialist.
HMO Emergencies ...
In a Medicare HMO, you cannot see doctors outside of the network unless you have an emergency. If you think you need emergency care, go to the nearest hospital emergency room. You do not need HMO approval for emergency care.
These are some examples of what may be emergencies:
- severe bleeding
- convulsions or seizures
- head or eye injuries
- poisoning or drug overdose
- difficulty breathing
- broken bones
- heart attack
- severe burns
- high fever
- severe pain
- chest pains
Leaving an HMO...
If you are unhappy with your Medicare HMO, you may leave it at any time through December 2001. This is called disenrolling.
If you wish to return to Original Medicare, tell your HMO or your local Social Security office in writing that you want to leave and return to Original Medicare. Keep a copy of your letter for yourself. You will be back in Original Medicare on the first of the following month if you disenroll by the tenth of the month.
To switch to another Medicare HMO, just sign up. You will be automatically disenrolled from your current HMO when your new coverage begins. You should check with your new HMO to find out when coverage begins.