#help.tut Extra help for tutorials #define.stb On line glossary- definitions of legal terms /* The following is information is distributed by the United States Social Security Administration concerns Medicare. As you will note the information refers to 1985. It is to our understanding the most current available information.*/ INFORMATION ABOUT MEDICARE 1. Introduction 2. Hospital Insurance Eligibility 3. Medical Insurance Eligibility 4. Hospital Insurance Benefits 5. Medical Insurance Benefits 6. Other Health Insurance /*SECTION 1 */ Introduction Medicare is a Federal health insurance program for people 65 or older, people of any age with permanent kidney failure, and certain disabled people. It is administered by the Health Care Financing Administration. Local Social Security Administration offices take applications for Medicare, assist beneficiaries in filing claims, and provide information about the program. Medicare has two parts; Hospital insurance helps pay for inpatient hospital care and certain followup care. Medical insurance helps pay for your doctor's services and many other medical services and items. Hospital insurance is financed through part of the Social Security tax. Voluntary medical insurance is financed from the monthly premiums paid by people who have enrolled for it and from general Federal revenues. Eligibility Requirements For Hospital Insurance 1 If You Are Nearing 65 2 If You Are Disabled 3 Permanent Kidney Failure If You Are Nearing Age 65 You do not have to retire to have hospital insurance at age 65. But if you plan to keep working, you will have to file an application in order for your hospital insurance protection to begin. You should apply at a Social Security office about 3 months before you reach 65. If you are receiving Social Security or railroad retirement checks, your hospital insurance will start automatically at 65. If you are a Federal retiree who is eligible for Medicare on the basis of Federal employment, you will have to apply for hospital insurance in order for it to begin at 65. Contact a Social Security office about 3 months before 65. If you are not eligible for hospital insurance at 65 you can buy it. The basic premium is $174 a month in 1985. To buy hospital insurance you also have to enroll and pay the monthly premium for medical insurance. You can apply at any Social Security office. If You Are Disabled If you are under age 65 and disabled, you will have hospital insurance protection automatically when you have been entitled to Social Security disability benefits for 24 months. If you are a widow or a widower between 50 and 65 years old and you have been disabled at least 2 years but haven't applied for disability benefits because you are getting other Social Security benefits, you may be eligible for hospital insurance. Contact a Social Security office for information. If you are a Federal employee and you become disabled before 65, you may be eligible for Medicare on the basis of your Federal employment. But, because of a 29 month waiting period that will usually apply, the earliest your hospital insurance protection could start will be June 1985. For more information, contact any Social Security office. Permanent Kidney Failure If you, your spouse, or your dependent child needs kidney dialysis or a kidney transplant, contact a Social Security office to apply for Medicare. You can apply by phone, or a representative can visit you to take an application if you are unable to visit an office. If you are eligible for Medicare, your protection will start with the third month after the month you actually begin maintenance dialysis treatments. Under certain conditions, your coverage could start earlier. The people in the Social Security office can tell you exactly when your protection will begin. Medical Insurance Eligibility 1. Who Is Eligible 2. Who Must Apply 3. Initial Enrollment Period Who Is Eligible Almost anyone who is 65 or older or who is eligible for hospital insurance can enroll for Medicare medical insurance. You don't need any Social Security or Federal work credits to get medical insurance. If you want medical insurance, you pay a monthly premium for this protection. The basic premium is $15.50 a month in 1985. Some people are automatically enrolled in medical insurance, others must apply. See the section entitled "Who Must Apply" for more details. Who Must Apply If you are receiving Social Security benefits or retirement benefits under the railroad retirement system, you will be automatically enrolled for medical insurance, unless you say you don't want it, at the same time you become entitled to hospital insurance. /*Thus you need to inform the Social Security Administration if you do not require Medicare because you have adequate other insurance.*/ You will have to apply for medical insurance if you: - plan to continue working past age 65; - are 65 but aren't eligible for hospital insurance; - have a permanent kidney failure; - are a disabled widow or widower between 50 and 65 who isn't getting disability checks; - are eligible for Medicare on the basis of Federal employment; - live in Puerto Rico or outside the U.S. Contact your local Social Security office or railroad retirement office for detailed information about medical insurance enrollment. Initial Enrollment Period There is a seven month initial enrollment period for medical insurance. This period begins three months before the month you first become eligible for medical insurance and ends three months after that month. For example, if you are eligible for medical insurance in July, your initial enrollment period starts April 1 and ends October 31. If you don't take medical insurance during your initial enrollment period, you can sign up during a general enrollment period, January 1 through March 31 of each year. But if you enroll during a general enrollment period, your protection won't start until the following July and your monthly premium will be 10 percent higher than the basic premium for each 12 month period you could have been enrolled but were not. /*There is a penalty for enrolling late, so apply on time!*/ Special rules apply to workers and their spouses age 65 through 69 who have employer group health coverage. See the section entitled "Other Health Insurance" for more information. Hospital Insurance Benefits 1. Inpatient Hospital Care 2. Skilled Nursing Facility Care 3. Home Health Care 4. Hospice Care Inpatient Hospital Care Medicare hospital insurance can help pay for inpatient hospital care. Hospital insurance helps pay for up to 90 days in any participating hospital in each benefit period. In 1985, hospital insurance pays for all covered services for the first 60 days, except for the first $400. For the 61st through the 90th day, hospital insurance pays for all covered services except for $100 a day. If you ever need more than 90 days of hospital care in any benefit period, you can use some or all of your 60 non-renewable reserve days. For each reserve day you use, hospital insurance pays for all covered services except for $200 a day. Covered services include semiprivate room, all meals, regular nursing services, operating and recovery room costs, hospital costs for anesthesia services, intensive care and coronary care, drugs, lab tests, X-rays, medical supplies and appliances, rehabilitation services, and preparatory services related to kidney transplant surgery. Skilled Nursing Facility Care If you need inpatient skilled nursing or rehabilitation services after a hospital stay and meet certain other conditions, hospital insurance helps pay for up to 100 days in a participating skilled nursing facility in each benefit period. In 1985, hospital insurance pays for all covered services for the first 20 days and all but $50 a day for up to 80 more days. Covered services include semiprivate room, all meals, regular nursing services, rehabilitation services, drugs, medical supplies, and appliances. Home Health Care If you are confined to your home and meet certain other conditions, hospital insurance can pay the full approved cost of home health visits from a participating home health agency. There is no limit to the number of covered visits you can have. Covered services include part-time skilled nursing care, physical therapy, and speech therapy. If you need one or more of those services, hospital insurance also covers part-time services of home health aides, occupational therapy, medical social services, and medical supplies and equipment. Hospice Care Under certain conditions, hospital insurance can help pay for hospice care for terminally ill beneficiaries if the care is provided by a Medicare-certified hospice. Special benefit periods apply to hospice care. Hospital insurance can pay for a maximum of two 90-day periods and one 30-day period. Covered services include doctor's services, nursing services, medical appliances and supplies including outpatient drugs for pain relief, home health aide and homemaker services, short-term inpatient care including respite care, and counseling. Hospital insurance pays part of the cost of outpatient drugs and inpatient respite care. For all other covered services, hospital insurance pays the full cost. Medical Insurance Benefits 1. Annual Deductible 2. Doctor's Services 3. Other Medical Services Annual Deductible Medicare medical insurance helps pay for your doctors' services and a variety of other medical services and supplies that are not covered by hospital insurance. Most of the services needed by people with permanent kidney failure are covered only by medical insurance. Each year, as soon as you meet the annual medical insurance deductible, medical insurance generally will pay 80 percent of the approved charges for covered services you receive during the rest of the year. In 1985, the annual deductible is $75. Doctors' Services Medical insurance covers doctors' services no matter where you receive them in the United States. Covered doctors' services include surgical services, diagnostic tests and X-rays that are part of your treatment, medical supplies furnished in a doctor's office, services of the office nurse, and drugs which are administered as part of your treatment and cannot be self-administered. Other Medical Services Medical insurance covers outpatient hospital services you receive for diagnosis and treatment, such as care in an emergency room or outpatient clinic of a hospital. Medical insurance can also cover an unlimited number of home health visits if all required conditions are met. Under certain conditions or limitations, medical insurance covers other medical services and supplies. Some examples are: ambulance transportation; home dialysis equipment, supplies, and periodic support services; independent laboratory tests; oral surgery; outpatient physical therapy and speech pathology services; and X-rays and radiation treatments. Other Medical Insurance 1. What Medicare Won't Pay 2. Other Health Plans 3. Buying Supplemental insurance 4. Employer Health Plans What Medicare Won't Pay For Medicare provides basic protection against the high cost of illness, but it will not pay all of your health care expenses. Some of the services and supplies Medicare cannot pay for are: custodial care, such as help with bathing, eating, and taking medicine; dentures and routine dental care; eyeglasses, hearing aids, and examinations to prescribe or fit them; personal comfort items such as a phone or TV in your hospital room; prescription drugs and patent medicines; and routine physical checkups and private room; and routine related tests. Other Health Plans Many private health insurance companies point out that their policies for people who have Medicare are designed only to supplement Medicare. They recommend that their policyholders sign up for Medicare medical insurance to have full protection. If you have other health insurance, it may not pay for some of the services that are covered by Medicare medical insurance. You should get in touch with your insurer or agent to discuss your health insurance needs in relation to Medicare protection. This is particularly important if you have dependents who are covered under your present policy. If you have health care protection from the Veterans Administration, the Indian Health Service, a Federal employees' health plan, or a State medical assistance program, the people there can probably help you to decide whether it is to your advantage to have Medicare medical insurance. Be sure not to cancel any health insurance you now have for your own protection until the month your Medicare coverage begins. Buying Supplemental Insurance If you are thinking about buying private insurance to supplement Medicare, please examine the policy carefully. Make sure it does not simply duplicate your Medicare coverage. If you want help in deciding whether to buy private supplemental insurance, ask at any Social Security office for the pamphlet, "Guide To Health Insurance For People With Medicare". This free pamphlet describes the various types of supplemental insurance available. Employer Group Health Plans Employers with 20 or more employees are required to offer workers and their spouses age 65 through 69 the same health benefits that are offered to younger workers. If you work past 65 and accept your employer's health plan, Medicare will be the secondary health insurance payer. If you reject your employer's health plan, Medicare will be the primary health insurance payer. Also, if you are 65-69 and continue to work (or are a spouse 65-69) and have an employer health plan, you can wait to enroll in Medicare medical insurance during a special enrollment period. You won't have to pay the 10 percent premium surcharge for late enrollment, if you meet certain requirements. For more information about these special rules, contact your employer. If you are entitled to Medicare solely on the basis of permanent kidney failure and you are covered by an employer group health plan, Medicare will be the secondary payer for an initial period of up to 12 months. At the end of the 12-month period, Medicare becomes the primary payer.