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The Medicare Maze

If you are newly injured and need information about disability benefits, or if you're approaching age 65, and looking at retirement, then it might be time to check out Medicare and its many options.

What is Medicare?
Medicare is a federal health insurance program for persons who are disabled and have received Social Security Disability Insurance (SSDI) for at least 24 months, and for persons 65 years of age or older. Medicare has two parts:

Part A covers inpatient hospitalization, skilled nursing facility care, and hospice care. It covers all but the first three pints of blood per year. Medicare will also pay for some home health care services. However, to get these services you must need skilled care and you must be homebound. Skilled care includes catheter changes and dressing of wounds; it does not include help to get out of bed, get dressed, have a meal prepared or be fed. Homebound basically means that you get out infrequently for only short durations, and for medical appointments. Different health care agencies interpret the term home-bound differently, so check with each. Some won't consider you homebound if you still own and drive your own vehicle.

Most people don't have to pay premiums for Part A coverage, but you will have deductibles to pay.

Part B covers both inpatient and outpatient medical services, as well as outpatient therapies, limited medical supplies and medical tests, and some durable medical equipment. In 2000, everyone in Part B will pay $45.50/month, which is deducted from your Social Security check or paid quarterly. You are also required to pay a $100 deductible each year, as well as a copayment for each visit or service. Although the formula the government uses to calculate these copayments is changing, copayments are not to exceed $776 per service.

Part A and Part B benefits don't cover the same things. You can have just Part A, or both A and B, but you can not get just Medicare Part B.

You are eligible for Medicare if you meet any of these criteria:

  • You are disabled and have received SSDI benefits for at least 24 months.
  • You were disabled before the age of 22 and are receiving Social Security benefits because a parent is disabled, deceased, or retired.
  • You are 65 and have paid into Social Security or a Railroad Retirement fund.

By law, you cannot be excluded from Medicare because of your disability - However, remember that your actual benefits can be affected by other insurance coverages you may have.

When Do I Apply?
Once you start receiving Social Security you are automatically enrolled into Medicare Part A. For Medicare B, you need to apply during a specific enrollment period. That period begins three months before your birth month in your 65th year and ends three months after your birth month in that same year. If you're applying because of a disability, the enrollment period begins 21 months after you first receive SSDI - regardless of your age. If you miss the enrollment periods, there's a general enrollment from January 1 to March 31 each year.

How Do I Apply?
If you are disabled and have received SSDI for two years, call Medicare at 1-800-MEDICARE (1-800-633-4227) to sign up. If you are retiring at age 65, call Social Security's toll-free information line - 1-800-772-1213. A representative will arrange a local phone interview with you. During that interview, he or she will confirm information needed for your application. You will receive documentation of the interview, including the amount of your monthly checks, less payment for Medicare Part B.

Medicare Choices:
You're not done yet. You have two more things to do:

  • Choose the type of Medicare package or option you want.
  • Explore "Medigap" or Medicare Supplemental Insurance.

The original Medicare plan is available to everyone on Medicare, but some of the other options vary from state to state.

Original Medicare:You can use almost any doctor, hospital or other health care provider in the country who accepts Medicare patients. Your provider is paid for each service you receive. You will have some out-of-pocket costs for your care. Your medications will not be covered. However, you can choose to enroll in - and pay for - Medigap, also known as Medicare Supplemental Insurance. This additional insurance may fill many of the gaps in Medicare coverage.

Managed Care Options: In these options, Medicare pays a fixed amount of money to your health plan for all of your care, no matter how few or how many services you need. If it's a Medicare Health Maintenance Organization (HMO), you must pick a Primary Care Physician (PCP) from an approved list. The PCP gives you basic health care and refers you for specialty care when he or she deems it appropriate. Generally, you have coverage only for care from your own HMO. In emergencies or when out of the health plan's area, your HMO will pay for your care if you follow their rules.

Some HMOs offer a costlier Point of Service (POS) option. This allows you to see providers outside the network with the HMO still covering part of the cost.

Other managed care options include Provider-Sponsored Organizations (PSOs) and Medicare Preferred Provider Organizations (PPOs). PSOs are like HMOs, but they are run by a group of doctors - in cooperation with a local hospital. They provide Medicare, parts A & B, for patients. PPOs are like HMOs that have a POS option. You can see any doctor who happens to be in your plan without clearing it with your primary care provider first. And, if you use a doctor who is outside the plan, you will still get some coverage. However, your out-of-pocket costs will be higher than an HMO.

As you can see, it's all very confusing. With any of these managed care plans, you'd be wise to find out exactly what's covered - and perhaps even get pre-authorization - before seeking out a particular service or provider.

Medicare Private Fee-For-Service (PFFS) Plan: Like original Medicare, you can use any doctor or health care provider, and the plan will cover your care. However, you will have higher out-of-pocket costs and higher monthly premiums than under Original Medicare.

Bridging the Gap:
Medigap Options
Medicare - Original or Managed Care options - pays only a percentage of "reasonable and customary" charges. The difference between Medicare's coverage and your actual medical bills is the "medigap." Private insurance companies sell Medicare Supplemental (Medigap) Insurance policies to fill the "gaps."

In most states insurers can only sell you Medicare supplemental policies that are one of 10 standard types. Each type (labeled with the letters A through J) provides additional coverage in some areas. They may pay for some or all of the Medicare co-insurance amounts; some or all deductibles; and certain services not covered by the original Medicare plan - such as outpatient prescription drugs, some preventative screenings, some care in your home, or emergency medical care for travel outside the US. Some policies provide coverage of doctor or hospital charges that are beyond the amount Medicare will pay.

Each of the ten different types of Medigap policies also offers a "SELECT" version. These usually cost you less than comparable non-select Medigap policies, but they require you to use doctors and hospitals in a defined network in order for you to be eligible for full benefits.

Which Do I Choose?
First, what do you need? If medications are a big bill item and you need annual exams that include special procedures, then one of the Medigap programs might be best. If cost is not a big concern and you want to choose your own docs and specialists, then Medicare's planned Private Fee For Service (PFFS) plan might be your best choice. Original Medicare is the least expensive option, but it's limited in what it covers. For example, it doesn't cover medications. Study the options and talk to your doc if you need to.

Many HMOs carry Medicare-related insurance and do not have any age restrictions. However, some are designed just for retirees. If you are not of retirement age but receive SSDI and need to sign up for Medicare, ask if the insurance company has any age restrictions.

Help for People on Fixed Incomes
If you can't afford Medicare B, you may qualify for other benefits, like Qualified Medicare Beneficiary (QMB), Specified, Low-Income Medicare Beneficiary (SLMB), or Qualifying Individuals 1 (QI-1). These programs are state-managed and must be applied for in your own state. Look for Medicaid in your phone book in the government section or in your county health or social services section.

Resources for more information:
Medicare 1-800-MEDICARE (1-800-633-4227). Ask for the book Medicare and You: Original Medicare Plan & Other Health Plan Choices.
Medicare Web Site: http:www.medicare.gov, In addition, your state's Web site may provide Medicaid information at www.state.XX.us (replace XX with the two-letter abbreviation for your state).

This is part of a library of educational brochures developed by Craig Hospital with a federal grant titled, "Marketing Health Promotion, Wellness, and Risk Information for Spinal Cord Injury Survivors in the Community." The opinions expressed here are not necessarily those of the funding agency, the National Institute on Disability and Rehabilitation Research of the US Department of Education.

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