Medicare Insurance: Eligibility, benefits, qualify for supplemental help

[NRSKarenRN, BSN, RN]

this week i've spent 10 hours doing 3 way phone calls with patients to medicare. spent 4 hours on just one patient as needed vietnamase translater ---which medicare provides for free. though i'd share general info you can discuss with patients/family members.

medicare

medicare eligibility, enrollment, and premiums. search for medicare plans, nursing homes, dialysis facilities, medigap insurance, medical assistance...

what is medicare?

medicare part a helps cover your inpatient care in hospitals, critical access hospitals and skilled nursing facilities. it also covers hospice care and some home health care.

medicare part b helps cover your doctors’ services, outpatient hospital care, and some other medical services that medicare part a doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. medicare part b helps pay for these covered services and supplies when they are medically necessary. for more coverage information go to your medicare coverage.

the medicare part b premium in 2008 is $96.40 for those with incomes less than $164,000. this monthly premium is deducted from your social security, railroad retirement, or civil service retirement check. if you don't get any of these payments, medicare will either send you a bill for your part b premium every 3 months or you can use medicare easy pay as an electronic payment option. this payment option allows people with medicare to have their medicare premiums automatically deducted from either their savings or checking account free of charge. for more information on how to sign up, go to the medicare easy pay faq.

who is eligible for medicare?

generally, you are eligible for medicare if you or your spouse worked for at least 10 years in medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the united states. if you aren’t yet 65, you might also qualify for coverage if you have a disability or with end-stage renal disease (permanent kidney failure requiring dialysis or transplant).

here are some simple guidelines. you can get part a at age 65 without having to pay premiums if:

• you already get retirement benefits from social security or the railroad retirement board.
  
• you are eligible to get social security or railroad benefits but haven't yet filed for them.
  
• you or your spouse had medicare-covered government employment.
  

if you are under 65, you can get part a without having to pay premiums if you have:

• received social security or railroad retirement board disability benefits for 24 months.
  
• end-stage renal disease and meet certain requirements.
  

while you don’t have to pay a premium for part a if you meet one of those conditions, you must pay for part b if you want it.

general enrollment period

initial enrollment period—the 7-month period that begins 3 months before your 65th birthday and ends 3 months after your 65th birthday.

drug coverage is available only during open enrollement period 11/15-12/31 each year. during this timeframe you can also switch your time of medicare benefits to medicare hmo or medicare advantage plan >>> enrollment period extended to march 31st, 2008 for medicare advantage plans this year.

if you didn’t sign up for medicare part b when you first became eligible, you may be able to sign up during the general enrollment period. this period runs from january 1 through march 31 of each year. during this time, you can sign up for medicare part b at your local social security office. if you get benefits from the railroad retirement board (rrb), call your local rrb office or 1-800-808-0772. your medicare part b coverage will start on july 1 of the year you sign up.

important: the cost of medicare part b will go up 10% for each full 12-month period that you could have had medicare part b but didn’t take it, except in special cases. you will have to pay this penalty as long as you have medicare part b.

if you already have medicare part a and need part b you can sign up for part b at your local social security office or by calling 1-800-772-1213

if you or your spouse is still working, see our faq: can i delay my medicare part b enrollment without paying higher premiums? you can delay your enrollment because you or your spouse are still working, the general enrollment period will not affect you until after you (or your spouse) stop working.

premium & cost information

part a: (hospital insurance)

deductible

• $1,024.00 (per benefit period)
  

coinsurance

• $256.00 a day for the 61st - 90th day each benefit period.
  
• $512.00 a day for the 91st - 150th day for each lifetime reserve day (total of 60 lifetime reserve days - non-renewable).
  

skilled nursing facility coinsurance

• up to $128.00 a day for the 21st - 100th day each benefit period.
  

hospice and home health care covered 100% (when considered homebound and post most hospitaliztions)

part b: (medical insurance)

deductible

• $135.00 per year. (note: you pay 20% of the medicare approved amount for services after you meet the $135.00 deductible.)
  

help to pay your health care costs

most of your health care costs are covered if you have medicare and you qualify for medicaid. medicaid is a joint federal and state program that helps pay medical costs for some people with limited incomes and resources. medicaid programs vary from state to state. people who have medicaid may also get coverage for nursing home care and outpatient prescription drugs which are not covered by medicare. you can find more information about medicaid on cms.hhs.gov.

states also have programs that pay some or all of medicare's premiums and may also pay medicare deductibles and coinsurance for certain people who have medicare and a low income.

a. extra help paying for medicare prescription drug coverage

what is this program?

you may qualify for "extra help" (the low-income subsidy) from medicare to pay prescription drug costs if you have a yearly income (in 2007) below $15,315 ($20,535 for a married person living with a spouse and no other dependents) and resources (in 2007) less than $11,710 ($23,410 for a married person living with a spouse and no other dependents). amounts will change in early 2008.

if you qualify for extra help in 2008, you will get the following:

• help paying your medicare drug plan’s monthly premium. depending on your income and resources and your plan’s premium, you may pay a reduced premium or no premium for a basic plan. for an enhanced plan, you must pay a portion of the premium for the extra coverage.
  
• help paying any yearly deductible
  
• help paying prescription coinsurance and copayments
  

you automatically qualify for extra help if you have medicare and meet one of these conditions:

• you have full medicaid benefits. see page 79.
  
• you get help from your state medicaid program paying your part b premiums (you belong to a medicare savings program). see page 80.
  
• you get supplemental security income (ssi) benefits without medicaid. see page 81. ■
  

if you didn’t automatically qualify for extra help, you can still apply ■

call social security at 1-800-772-1213 to apply by phone or to get a paper application.

b.medicare savings programs (help from medicaid to pay medicare premiums) states have programs for people with limited income and resources. these programs pay medicare premiums and, in some cases, may also pay medicare part a and part b deductibles and coinsurance. these programs help millions of people with medicare save money each year.

to qualify for a medicare savings program, you must meet these conditions:

• have medicare part a be an individual with resources of $4,000 or less, or a married couple with resources of $6,000 or less. resources include money in a checking or savings account, stocks, and bonds. resources don’t include your home, car, burial plot, up to $1,500 for burial expenses, furniture, or other household items.
  
• be an individual with a monthly income of less than $1,169, or a married couple with a monthly income of less than $1,561
  

note: individual states may have different income and/or resource limits. income limits will increase slightly in 2008 or if you have other dependents in your household. call your state medical assistance (medicaid) office. ■

c. supplemental security income (ssi) benefits

ssi is a monthly amount paid by social security to people with limited income and resources who are disabled, blind, or age 65 or older. ssi benefits provide cash to meet basic needs for food, clothing, and shelter. ssi benefits aren’t the same as social security benefits

contact social security to apply.

d. programs of all-inclusive care for the elderly (pace)

called life program in pa ---pace is state pharmaceutical assistance program.

pace combines medical, social, and long-term care services for frail elderly people who live in and get health care in the community. pace programs provide all medically-necessary services, including prescription drugs. pace is a joint medicare and medicaid program that may be available in states that have chosen it as an optional medicaid benefit. pace might be a better choice for you instead of getting care through a nursing home.

to qualify for pace, you must meet these conditions:

• be at least age 55 live in the pace service area
  
• be certified by your state as eligible for nursing home care
  
• call your state medical assistance (medicaid) office to find out if you are eligible and if there is a pace site near you. you can also visit www.cms.hhs.gov/pace on the web for pace
  

list of pace provider organizations

get information 24 hours a day, including weekends.

call 1-800-medicar (1-800-633-4227). tty: 1-877-486-2048.

[NRSKarenRN, BSN, RN]

i am repeatedly asked: who is responsible for medicare bills?

individual person is responsible for part a deductible and co-insurance in hospital and snf; part b deductible and 20% copay.

if person has secondary insurance, that insurance will often pick up the part a deductible and co-insurance and part b copay.

if the person does not have secondary coverage, then the bill becomes debt and is treated as such similar to if home payments, car payments, electric bill or taxes not paid.

many healthcare organizations will try and identify if person eligible for medicaid or social security programs b + c mentioned above ---but person has to apply and qualify retroactively to date of bill in order to get medical debt cleared.

regarding skilled nursing home payment:

those persons who exhaust the 100day benefit, can spend down personal income to qualify for medical assistance. income limits vary by state medicaid program. if spouse/ child living in patients home and providing upkeep, home assest will not be included until death of spouse or child sells home ---this is called estate recovery. medicaid looks at bank records previous 3 years to acertain assests---and make sure monies not transfered to child to cost shift burden of care onto the state.

[color=#0000cc]medicaid estate recovery

...surviving family members or heirs of medicaid recipients must not be asked to use their own funds to repay medicaid, except, possibly, in the case of an estate that includes the deceased recipient’s home. when home equity becomes part of the estate, it is subject to medicaid estate recovery. the survivors may either sell the home and use the proceeds to satisfy the medicaid claim or, if they wish to keep the home in the family, satisfy the claim with their own personal funds

states are prohibited from making estate recoveries:

• during the lifetime of the surviving spouse (no matter where he or she lives).
  
• from a surviving child who is under age 21, or is blind or permanently disabled (according to the ssi/medicaid definition of “disability”), no matter where he or she lives.
  
• in the case of the former home of the recipient, when a sibling with an equity interest in the home has lived in the home for at least 1 year immediately before the deceased medicaid recipient was institutionalized and has lawfully resided in the home continuously since the date of the recipient's admission.
  
• in the case of the former home of the recipient, when an adult child has lived in the home for at least 2 years immediately before the deceased medicaid recipient was institutionalized, has lived there continuously since that time, and can establish to the satisfaction of the state that he or she provided care that may have delayed the recipient’s admission to the nursing home or other medical institution.