Top Ten HICAP Questions
1. What is Medicare?
2. Who is eligible for Medicare?
3. Can I delay signing up with Medicare?
4. What does Medicare cover?
5. What doesn't Medicare cover?
6. What are my options to supplement Medicare coverage?
7. What is Medi-Cal and how does it differ from Medicare?
8. What are the Medicare Savings Programs?
9. What is the California Prescription Discount Program?
10. What is Long Term Care Insurance?
1. What is Medicare?
Medicare is the Federal health insurance program established in 1965. It covers most people age 65 and older, some people under 65 who are disabled and those with end-stage renal disease (ESRD). Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health Services.
Medicare is divided into two parts - Part A (Hospital Insurance) covers inpatient hospital care, some skilled nursing facility care, home health and hospice care. Part B (Medical Insurance) covers doctors' services, outpatient hospital care, outpatient physical and speech therapy, home health care, outpatient laboratory services. some preventive services, medical equipment and supplies and ambulance services.
2. Who is eligible for Medicare?
Most people are automatically eligible for Medicare Part A if they are 65 or older and are eligible for Social Security, Railroad Retirement of Federal Civil Service benefits on their own or their spouse's work history. Part A is also available to those people diagnosed with end-stage renal disease (ESRD), amotrophic lateral sclerosis (ALS) or to those that have been receiving Social Security Disability Insurance (SSDI) or Railroad Retirement Disability Insurance for 24 months.
Automatic eligibility indicates that there is no premium for Part A. For those who are age 65 or older and are not automatically eligible for Part A, they may be able to voluntarily enroll in Medicare for a monthly premium. The Social Security office can determine someone's eligibility for voluntary enrollment.
Any person who is eligible for Part A is also eligible to enroll in Part B. There is a monthly premium for all individuals enrolled in Part B. For 2008, the premium is $96.40 per month.
3. Can I delay signing up with Medicare?
Yes, if you or your spouse continue to work when you become eligible for Medicare, you can delay your enrollment in Medicare only if the employer has at least 20 employees. The employer, in this case, must offer you the same group health coverage as it offers younger employees.
If you are covered by an Employer Group Health Plan (EGHP) and delay taking Medicare Part B when you are first eligible, you can enroll in Medicare at any time until the end of eight months after your employer plan ends or when you stop working. This is called a Special Enrollment Period (SEP). If you delay enrolling in Medicare Part B during this period, you are not able to sign up until January through March of the following year with an effective enrollment date of July 1st. This is called the General Enrollment Period. You may also have to pay a penalty that increases your monthly Part B premium.
4. What does Medicare cover?
Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Part A covers inpatient hospital stays, skilled nursing facility (SNF) care, some home health care, and hospice care. Covered services in a hospital include a semi-private room, meals, general nursing care, and other hospital services and supplies. Covered services in a skilled nursing facility include a semi-private room, meals, skilled nursing care, physical, language and occupational therapy, medical social services, medications and supplies. For Part A services, there are affiliated deductibles and coinsurances.
Part B helps pay for doctors' services, outpatient medical and surgical supplies, diagnostic tests, outpatient rehabilitation therapy, some preventive health services and ambulance services. Medicare generally will only pay for care that is considered medically necessary. There is a $100 annual deductible for Part B services and then Medicare generally pays 80% of the approved charges.
5. What does Medicare not cover?
There are various health services and products that Medicare does not cover. These include eyeglasses (except for lenses after cataract surgery), hearing aids, routine eye and foot care, care outside of the United States, long-term care, most outpatient prescription drugs, dental care, cosmetic surgery and annual routine physical examinations. Although some personal care services (i.e. assistance with bathing, dressing, eating) are not covered alone by Medicare, these services may be covered if they are provided in combination with skilled services. The one exception would be if these services were provided as part of the hospice benefit.
6. What are my options to supplement Medicare coverage?
Most people have additional coverage to supplement the gaps in Medicare coverage. The gaps include the deductibles, co-insurances and services that Medicare does not cover. Options to supplement Medicare coverage include (1) Medicare+Choice plan (Medicare HMO) - must check for availability in your area, (2) Private Medicare supplemental insurance policy - works with fee-for-service Medicare, (3) Retirement policy - supplied by an employer group plan, (4) Tricare-for-Life - for military retirees and their spouses, and (5) State assistance programs - i.e. Medi-Cal (California's Medicaid program).
7. What is Medi-Cal and how does it differ from Medicare?
Medi-Cal is the name for California's Medicaid program. Medi-Cal provides health coverage to people with low income and limited resources. Many individuals receive both Medicare and Medi-Cal.
Medicare is a federal health insurance program for people age 65 and older and some disabled individuals regardless of income and assets. Medi-Cal, is an assistance program jointly funded by federal and state funds for low-income eligible individuals who are 65 or older, blind or disabled. To qualify for Medi-Cal, your income must not exceed a certain amount (this amount changes every year) and your assets may not exceed $2,000 for an individual and $3,000 for a couple. To see if you qualify for Medi-Cal, contact your local Department of Social Services.
8. What are the Medicare Savings Programs?
There are several programs that assist people with paying for health care costs who have low income and asset levels. These programs are known as QMB (Qualified Medicare Beneficiary), SLMB (Specified Low Income Medicare Beneficiary), QI-1 (Qualified Individual Program) and QDWI (Qualified Disabled Working Individual) programs.
QMB program helps pay for the Medicare Part A premium ($410/month in 2008), Part B premium, deductibles for both Part A and Part B and the co-insurance for both Part A and Part B.
SLMB/QI-1 programs help pay for the Part B premium.
QDWI program is available to people who had Social Security and Medicare because of disability but who have lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the
limit allowed. QDWI pays the part A premium, but does not pay the Part B premium.
9. What is the California Prescription Discount program?
This program went into effect on February 1, 2000. This program entitles people with Medicare to go in to any California pharmacy that accepts Medi-Cal and receive prescriptions at the Medi-Cal rate plus a 15-cent processing fee. This program is intended to give Medicare beneficiaries a discount from retail prescription prices. Anyone with a Medicare card can participate and you do not have to be a Medi-Cal recipient to be eligible for this program. Just take your prescription to any California pharmacy that accepts Medi-Cal and present your prescription and your Medicare card. Medi-Cal will not pay for the prescription, but you will pay the Medi-Cal prescription cost plus the processing fee. There are no forms to fill out - your Medicare card is proof of your eligibility.
10. What is Long Term Care Insurance?
Long Term Care Insurance is a type of insurance that only pays for long term care. Some of these policies pay for care in institutional settings only such as a skilled nursing or assisted living facility. Some policies pay for care in the home while some policies are more comprehensive and pay for care in a nursing home, an assisted living facility, at home and in community settings like adult day care.
If you are considering buying long-term care insurance you will need to do some research to find the best combination of benefits for you and the best company for those benefits. You may also need assistance to help you understand how these benefits work, help you compare benefits and features of several policies or compare policies from different companies. Trained and registered HICAP Long Term Care counselors can help you sort through some of these issues.