Archive for the ‘Medicare’ Category

Important Links

Wednesday, May 26th, 2010

medicareandyou

Medicare & You

yourmedicarebenefits An Explanation of Part A and Part B Benefits

Important Contacts

Call:

With your questions about:

1-800-MEDICARE
(1-800-633-4227)

www.medicare.gov
24 hours a day
TTY users should call
1-877-486-2048

  • Medicare (in general)
  • Medicare health plans
  • Ordering Medicare booklets
  • Medigap policies
  • Assistance Programs for Medicare Part B (limited income – ask about the Medicare Savings Programs)
  • Telephone numbers for local organizations who work with medicare, including TTY numbers

Social Security Administration
1-800-772-1213
TTY users should call
1-800-325-0778

  • Address/name changes
  • Death notification
  • Enrolling in Medicare
  • Medicare card (replacement)
  • Social Security benefits
  • Limited Income – you may be eligible for help paying for Prescription Drug Coverage under Medicare Part D

Medigap Policies

Wednesday, May 26th, 2010

365.118 - family recognitionA Medigap policy is a health insurance policy sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. Medigap policies must follow federal and state laws. These laws protect you. The front of the Medigap policy must clearly identify it as “Medicare Supplement Insurance.”

In all states, except Massachusetts, Minnesota, and Wisconsin, a Medigap policy must be one of twelve standardized policies so you can compare them easily. Each policy has a different set of benefits. Two of the standardized policies may have a high deductible option. In addition, any standardized policy may be sold as a “Medicare SELECT” policy. Medicare SELECT policies usually cost less because you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits from the policy. In an emergency, you may use any doctor or hospital.

Click image to view guide to Medigap Policies

Outline of Medicare Supplement Coverage

(Benefit Plans A-L)

Medicare Supplement Insurance can be sold in only twelve standard plans. This chart shows the benefits included in each plan. Every company must make available Plan “A”. Some plans may not be available in your state as indicated below.

A B C D E F* G H I J* K L
Medicare Part A Coinsurance & Medigap Coverage for Hospital Benefits
Medicare Part B Coinsurance or Copayment 50%* 75%*
Blood (First 3 pints) 50%* 75%*
Hospice Care Coinsurance or Copayment 50%* 75%*
Medicare Part A Deductible 50%* 75%*
Skilled Nursing Facility Care Coinsurance 50%* 75%*
Medicare Part B Deductible
Medicare Part B Excess Charges 80%
Foreign Travel Emergency (Up to Plan Limits)
At Home Recovery (Up to Plan Limits)
Preventive Care Coinsurance (Included in the Part B Coinsurance)
Preventive Care not Covered by Medicare (up to $120)
**Out-of-Pocket Limit $4,620** $2,310**

Plans A-L are standardized by the federal government. Not all plans may be available in your area. Consider the benefits offered by each plan and look for one that best meets your individual needs.

*Medigap Plans F and J also offer a high-deductible plan. You must pay the high-deductible ($2,000 in 2010) amount before your Medigap-covered costs before pays anything..

**After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($155 in 2010), the plan pays 100% of covered services for the rest of the calendar year. Out-of-pocket limit is the maximum amount you would pay for coinsurance and copayments

Medicare Part D

Wednesday, May 26th, 2010

Medicare started offering insurance coverage for prescription drugs through Medicare prescriptions drug plans and other health plan options. Medicare’s prescription drug coverage will typically pay over half of your drug costs, for a monthly premium. It will also provide peace of mind because it protects you once you have spent your plan’s out-of-pocket drug spending limit, you pay 5% of the costs and Medicare pays 95% of the costs for the rest of the year. Even if you don’t use a lot of prescription drugs now, you should consider joining.

Important points you need to know:

  • Medicare prescription drug coverage helps you pay for the prescriptions you need.
  • Medicare prescription drug coverage is available to all people with Medicare.
  • There is additional help for those who need it most.
  • Medicare prescription drug coverage pays for brand name as well as generic drugs.

Your Medicare Prescription Drug CoveragePrescribed

Basic Information

What is Medicare prescription drug coverage?

Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.

Who can get Medicare prescription drug coverage?

Everyone with Medicare is eligible for this coverage, regardless of income and resources,health status, or current prescription expenses.

When can I get Medicare prescription drug coverage?

You may sign up when you first become eligible for Medicare (three months before the month you turn age 65 until three months after you turn age 65). If you get Medicare due to a disability, you can join from three months before to three months after your 25th month of cash disability payments. If you don’t sign up when you are first eligible, you may pay a penalty. If you didn’t join when you were first eligible, your next opportunity to enroll will be from November 15 to December 31.

How does Medicare prescription drug coverage work?

Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. There are two ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other Medicare Health Plan that offers drug coverage.

Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.

Like other insurance, if you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescription, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting socialsecurity.gov.

Why should I get Medicare prescription drug coverage?

Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. Even if you don’t use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means protection from unexpected prescription drug bills in the future.

What if I have a limited income and resources?

There is extra help for people with limited income and resources. Almost 1 in 3 people with Medicare will qualify for extra help. If you qualify for extra help, Medicare will pay for almost all of your prescription drug costs. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting socialsecurity.gov.

Things to Consider

Cost


Premium

There is a monthly cost you pay to join a Medicare drug plan. Premiums vary by plan.

Deductible

This is the amount you pay for your prescriptions before your plan starts to share in the costs. Deductibles vary by plans. Some plans may not have any deductible.

Copayment/Coinsurance

This is the amount you pay for your prescriptions after you have paid the deductible. In some plans, you pay the same copayment (a set amount) or coinsurance (a percentage of the cost) for any prescription. In other plans, there might be different levels or “tiers,” with different costs. (For example, you might have to pay less for generic drugs than brand names. Or, some brand names might have a lower copayment than other brand names.) Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.

Coverage


Formulary

A list of drugs that a Medicare drug plan covers is called a formulary. Formularies include generic drugs and brand-name drugs. Most prescription drugs used by people with Medicare will be on a plan’s formulary. The formulary must include at least two drugs in categories and classes of most commonly prescribed drugs to people with Medicare. This makes sure that people with different medical conditions can get the treatment they need.

Prior Authorization

Some drugs are more expensive than others even though some less expensive drugs work just as well. Other drugs may have more side effects, or have restrictions ono how long they can be taken. To be sure certain drugs are used correctly and only when truly necessary, plans may require a “prior authorization.” This means before the plan will cover these prescriptions, your doctor must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered. Plans might have other rules like this to ensure that your drug use is effective.

Coverage Gap

If you have high drug costs, you may consider which plans offer additional coverage until you spend $4,050 (in 2008) out-of-pocket. In some plans, if your costs reach an initial coverage limit, then you pay 100% of your prescription costs. This is called the coverage gap. Some plans might offer some coverage during the gap. Even in plans where you pay 100% of covered drug costs after a certain limit, you would still pay less for your prescriptions than you would without this drug coverage.

Convenience

Drug plans must contract with pharmacies in your area. Check with the plan to make sure your pharmacy or a pharmacy in the plan is convenient to you. Also, some plans may offer a mail-order program that will allow you to have drugs send directly to your home. You should consider all of your options in determining what is the most cost-effective and convenient way to have your prescriptions filled.

Peace of mind now and in the future

Even if you don’t take a lot of prescription drugs now, you still should consider joining a drug plan. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay a lower monthly premium in the future since you may have to pay a penalty if you choose to join later. You will have to pay this penalty as long as you have a Medicare drug plan. If you reach the point where you have spent your plan’s out-of-pocket drug costs during the year, the plan will pay most of your remaining drug costs. This protection could start even sooner in some plans.

Medicare Part B (2010)

Wednesday, May 26th, 2010

Part B is Medical Insurance and covers physicians services, outpatient care, test, and supplies.

On Expenses
incurred for:
Medicare Covers You Pay $155 Annual Part B Deductible PLUS

Physicians services, inpatient, outpatient medical/surgical services, physical/speech therapy, diagnostic test.

80% of approved amount 20% of approved amount
Clinical Laboratory Services
Blood Test, Urinalysis
Generally 100% of approved amount Nothing for Services
Home Health Care
Part-time or intermittent skilled care, home health aide services, durable medical supplies and other services.
100% of approved amount; 80% of approved amount for durable medical equipment Nothing for Services; 20% of approved amount for durable medical equipment
Outpatient Hospital Treatment
Services for the diagnosis or treatment of an illness or injury
Medicare payment to hospital based on hospital cost 20% of Billed Amount
Blood

After first 3 pints of blood, 80% of approved amount

First 3 pints plus 20% of approved amount for additional pints

On all Medicare-covered expenses, a doctor or other health care provider may agree to accept Medicare “assignment.” This means the patient will not be required to pay any expense in excess of Medicare’s “approved” charge. The patient pays only 20% of the “approved” charge not paid by Medicare.

Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge for covered services.

Medicare Healthcare Plans Quote

Wednesday, May 26th, 2010

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Part I – Applicant Information

Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Spouse Information
Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Applicant Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Email Address
Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.
A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?
If yes, please describe
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?
If yes, please describe
B. Do you have any other health insurance coverage that provides Medicare benefits?
If so, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program:
1. As a Specified Low-Income Medicare Beneficiary (SLMB)
2. As a Qualified Medicare Beneficiary (QMB)
3. For other Medicaid medical benefits?
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insured)
Within the past two (2) years have you had, or had a medical diagnosis of:
a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?
e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?
2. Are you an insulin dependent diabetic taking more than 50 units per day?
3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?
4. Are you currently hospitalized, or receiving Medicare approved home health care; or have you been hospitalized or received Medicare approved home health care three or more times in the past two years?
5. Within the past year have you been medically advised to have surgery but not had such surgery?

Medicare Part A (2010)

Friday, May 21st, 2010

Part A is Hospital Insurance and covers cost associated with confinement in a hospital or skilled nursing facility.

When you are hospitalized for: Medicare Covers You Pay
1-60 Days Most confinement costs after the required Medicare Deductible $1,100 Part A Deductible
61-90 Days All eligible expenses, after the patient pays a per-day copayment. $275/Day
91-150 Days All eligible expenses, after patient pays per-day copayment.


(These Are Liftetime Reserve Days Which may never be used again.)

$550/Day
151 days or more Nothing You Pay All Cost
Skilled Nursing
Confinement:
When you are hospitalized for at least 3 days and enter a Medicare Approved skilled nursing facility within 30 days after a hospital discharge and are receiving skilled nursing care.
All eligible expenses for the first 20 days; then all eligible expenses, (if you qualify), for days 21-100, after patient pays a per day copayment. After 20 days


$137.50/Day

Glossary

Friday, May 21st, 2010

Medicare Terms Defined

For Complete Glossary click here

Lifetime Reserve Days

are limited to 60 days during your life. After these reserve days are used, Medicare provides no hospital coverage after 90 days of a benefit period.

Medicare Eligible Expenses

are expenses which are recognized as reasonable and medically necessary by Medicare. Physicians under Medicare may accept Medicare’s Eligible Expense as their fee amount. Your physician may also charge you more.

Skilled Nursing Facility

provides skilled nursing care and is approved for payment by Medicare or may qualify to receive such approval. Custodial care is not an eligible expense.

Excess Charges

is the difference between the actual charge as billed, and the Medicare approved Part B charge.

Medicare (Part A)

Hospital Services for semiprivate room and board, general nursing and miscellaneous services and supplies. Benefit period applies.

Medicare (Part B)

Medical services in or out of the hospital and outpatient hospital treatment, such as physician services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment.

Benefit Period

defines the limit of a stay at a hospital or nursing facility and what benefits you receive for that stay.

Special Notes:

The sale of duplicate Medicare Supplement coverage is prohibited.
Your coverage can never be canceled because of your age, your health, or the number of claims you make as long as you make payments when due.
Consult your local insurance professional for specific information.

Introduction to Medicare

Friday, May 21st, 2010

The Medicare Program

Medicare is a health insurance program for:

  • People age 65 or older.
  • People under age 65 with certain disabilities.
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

The Original Medicare Has Two Parts

Part A

Hospital Insurance.

Most people pay for Part A through their payroll taxes when they are working.

Part B

Medical Insurance.

Most people pay monthly for Part B.

You can elect to participate in a Medicare Advantage Plan Part C and Medicare Prescription Drug Coverage Part D

Medicare Advantage Plans

You can choose different ways to get the services covered by Medicare. Depending on where you live, you may have different choices. In most cases, when you first get Medicare, you are in the Original Medicare Plan. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that provides all your Part A, Part B, and often Part D (Medicare Prescription Drug) coverage. You make a choice when you are first eligible for Medicare. Each year you can review your health and prescription needs and switch to a different plan in the fall.

Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called “Part C.” When you join a Medicare Advantage Plan, you are still in Medicare. As long as you have both Part A and Part B, items covered by Part A and Part B are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).

Part D

Prescription Drug Coverage

Medicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Medicare.

Medicare Health Plans

Today’s Medicare is about choice. Your health plan choices include:

  • The Original Medicare Plan
  • Medicare + Choice Plans, including:
  • Medicare Managed Care Plans
  • Medicare Private Fee-for-Service Plans
  • Medicare Preferred Provider Organization Plans

Medicare + Choice Plans are available in many areas.

The Medicare health plan that you choose affects many things like cost, benefits (some have extra benefits like prescription drugs), doctor choice, convenience, and quality.

What is Medicare Part A?

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.

Cost

  • Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
  • The part A premium is $254.00 per month for people having 30-39 quarters of Medicare-covered employment.
  • The Part A premium is $461.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
  • Medicare Part A Helps Cover Your Medically Necessary:

Hospital Stays

Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This doesn’t include private duty nursing, or a television or telephone in your room. It also doesn’t include a private room, unless medically necessary. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.
Skilled Nursing Facility Care

Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day inpatient hospital stay).

Home Health Care

Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Hospice Care

For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in your home. However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).

Blood

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

What is Medicare Part B?

Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A doesn’t 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.

Cost

You pay the Medicare Part B premium each month*. In some cases, this amount may be higher if you didn’t sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it, except in special cases. You will have to pay this extra amount as long as you have Part B.

Medicare Part B Helps Cover Your Medically Necessary:

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, and outpatient occupational and physical therapy including speech-language therapy. (These services are also covered for long-term nursing home residents).

Clinical Laboratory Services

Blood tests, urinalysis, some screening tests, and more.

Home Health Care

Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

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.

What is the Original Medicare Plan?

The Original Medicare Plan is a “fee-for-service” plan. This means you are usually charged a fee for each health care service or supply you get. This plan, managed by the Federal Government, is available nationwide. If you are in the Original Medicare Plan, you use your red, white, and blue Medicare card when you get health care. If you are happy getting your health care this way, you don’t have to change. You will stay in the Original Medicare Plan unless you choose to join a Medicare + Choice Plan.

Your costs in the Original Medicare Plan

What you pay out-of-pocket depends on:

  • Whether you have Part A and Part B
  • Whether your doctor or supplier agrees to accept “assignment”
  • How often you need health care
  • What type of health care you need
  • Whether you choose to get services or supplies not covered by Medicare. In this case, you would pay for these services yourself.
  • Whether you have other insurance