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Frequently Asked Questions and Answers
1. What does Part A cover?
Part A covers:
♦ Hospital Inpatient Care
♦ Skilled Nursing Facility (SNF) Care
♦ Home Health Care
♦ Hospice Care
Be aware that each type of care has its own set of criteria that must be met in order for Medicare to cover it. There are also limits on the amount of care that will be covered.
2. What does Part B cover?
Part B covers:
Medically necessary services including ambulance services, blood, chiropractic services (limited), laboratory services, some diabetes supplies, doctor services, durable medical equipment (DME), emergency room services, home health services, kidney dialysis services and supplies, mental health care, occupational therapy, outpatient hospital services, physical therapy, preventive services, speech therapy, and tests including x-rays, MRIs, CT scans, and EKGs. Also preventive services such as:
♦ Abdominal aortic aneurysm screening
♦ Annual Wellness Screening (physical)
♦ Bone mass measurement
♦ Cardiovascular screenings
♦ Colorectal cancer screenings
♦ Diabetes screenings and self-management training
♦ Flu shots
♦ Glaucoma tests
♦ Hepatitis B shots
♦ Medical nutrition therapy services
♦ Pap Tests and pelvic exams
♦ Pneumococcal shot
♦ Prostate cancer screenings
♦ Smoking cessation
♦ “Welcome to Medicare” physical
Be aware that each service has its own set of criteria that must be met in order for it to be covered.
3. What are Medicare Advantage plans?
♦ Preferred Provider Organization (PPO) plans — NOTE: these are not Medigap plans
♦ Health Maintenance Organization (HMO) plans
♦ Private Fee-for-Service (PFFS) plans
♦ Medical Savings Account (MSA) plans
♦ Special Needs Plans (SNP)
You can find out which plans are offered in your area by:
♦ making an appointment with HICAP at 1-800-434-0222
♦ viewing the Medicare and You annual booklet
♦ going to the Medicare website, www.medicare.gov
4. How do I get Medicare prescription drug coverage?
You can get Medicare prescription drug coverage through:
♦ Stand-alone Part D plans offered by companies that contract with Medicare. To enroll in a Medicare Prescription Drug Part D Plan, you must have Medicare Part A and/or Part B.
♦ Medicare Advantage Plans. Most of these plans offer prescription drug coverage. To join a Medicare Advantage Plan, you must have Part A and Part B. Be aware that some Medicare Advantage plans do not offer prescription drug coverage. Patients enrolled in such plans may not join stand-alone prescription drug plans.
Medicare drug plans may be regional or national. If you are a “snowbird” and live a portion of each year in a different county or state, you should check whether the plan you are considering is available at each of your residences.
For more help, please contact HICAP at 1-800-434-0222.
Click here for a printable version of the Medicare Prescription Drug Plan Finder form.
5. What if I can’t afford a Medicare Part D plan?
If you have limited income and resources, you might qualify for help with Part D costs through the following programs:
♦ Low-Income Subsidy (LIS)
For more information, please contact HICAP at 1-800-434-0222.
6. What is Low-Income Subsidy (LIS)?
Low-Income Subsidy (LIS) offers help from Medicare to reduce prescription drug costs for those who meet the eligibility criteria. Those who qualify for Low-Income Subsidy have:
♦ Lower or no Part D plan premium.
♦ Discounted copayments.
♦ No coverage gap or “donut hole.”
♦ The right to change Part D plans month-to-month
You qualify for the Low-Income Subsidy if you have Medicare and meet one of these conditions:
♦ You have full Medi-Cal or Medicaid coverage. See Medi-Cal.
♦ You belong to a Medicare Savings Program. See Medicare Savings Program.
♦ You get Supplemental Security Income (SSI) benefits.
♦ Your income is below 150% of the Federal Poverty Level and you meet the LIS resource guidelines.
If you have Medi-Cal with a Share of Cost (SOC) or monthly deductible, you may still qualify for LIS even if your income is above 150% of the Federal Poverty Level. If you meet your SOC for any one month between January 1 to June 30, you are automatically “deemed” eligible for the LIS program for the rest of the calendar year. If you meet your SOC for any one month between July 1 to December 31, you are also “deemed” eligible for LIS for the rest of the calendar year plus the following year.
7. I am turning 65 soon! What should I know about Medicare benefits?
Now is the time to make important decisions regarding your health insurance needs!
If you are already collecting Social Security benefits, you should receive your Medicare card in the mail a few months prior to your 65th birthday. If you are not yet collecting Social Security, or if you are and have not received a Medicare card timely, contact the Social Security Administration at 1-800-772-1213 or www.ssa.gov.
Part A Hospital Insurance has no premium if you have paid 40 quarters into the Social Security system. Part B has a monthly premium based on your income.
NOTE: if you do not have a Medicare A & B, you will not be able to purchase Medigap supplemental insurance or a Medicare Advantage Plan.
If you have creditable health coverage through either your own or your spouse’s large employer group, you may be able to defer your Part B enrollment until you or your spouse is no longer working for the company. If the company has less than twenty employees, however, you will need to enroll in Part B. For more information, please see Enrollment Periods/Guaranteed Rights.
Last, but not least, contact HICAP for a one-on-one appointment to go over all your options for enrolling in Medigap, Medicare Advantage, and Medicare Part D prescription coverage. Or attend a “Welcome to Medicare” workshop. Call HICAP for more information at: 1-800-434-0222.
8. What are the different parts of Medicare?
Medicare Part A (Hospital Insurance): helps cover inpatient care in hospitals and skilled nursing facilities, as well as some home health care, and hospice.
Medicare Part B (Medical Insurance for Outpatient Services): helps cover physician services, x-rays, lab services, physical therapy, speech therapy, occupational therapy, outpatient procedures, and some preventive services.
Medicare Part C (Medicare Advantage): a health plan option administered through private insurance companies that contract with Medicare. Medicare Advantage Plans provide Part A and Part B coverage plus additional benefits and cost protections through a specific network of health providers. Most Part C plans also provide drug coverage. Medicare Advantage Plans are HMOs, PPOs, Private Fee for Service Plans (PFFS), Medicare Savings Plans, and Special Needs Plans. NOTE: if you are enrolled in a Medicare Advantage plan, you receive your health benefits through that plan rather than through Original Medicare.
Medicare Part D (Prescription Drug Coverage): helps cover the cost of prescription drugs. There are Stand-Alone plans and Medicare Advantage Plans with built-in Part D coverage.
9. What is Medigap (supplemental) insurance?
Medigap is private health insurance that covers the deductibles and copayments associated with Original Medicare Parts A & B. Depending on the Medigap policy, it is possible you will have no out-of-pocket expenses for hospital or outpatient care apart from the plan premium. Note: the Medigap plans currently offered for sale do not include Medicare Part D prescription coverage. You will need to purchase a Stand-Alone Part D plan.
10. What are the basic benefits of Medigap policies?
Medigap policies must follow federal and state laws designed to protect you when purchasing coverage. The policy must state that it is a Medicare Supplement Insurance. Insurance companies sell only standardized plans that are identified in most states by the letters A through N as of June 2010. Each individual, standardized Medigap policy must offer the same basic coverage no matter which company is selling it, though companies have the option of adding benefits to a policy. Cost is usually the only difference between specific Medigap policies sold by different companies.
A Medigap policy will be your secondary insurance to Original Medicare. If you have a Private Fee-for-Service (PFFS) plan, or a Medicare HMO or PPO under the Medicare Advantage program, it is illegal to purchase a Medigap policy unless you are switching back to Original Medicare.
NOTE: A Medigap policy will not cover the copays, coinsurance, or deductibles of a Medicare Advantage plan.
11. I’m disabled, how do I become eligible for Medicare?
If you qualify for Social Security Disability Insurance (SSDI), you may be eligible for Medicare even if you have not reached age 65. Medicare benefits generally will not be effective, however, until 24 months after the date Social Security determines you were disabled. People diagnosed with ALS (Lou Gehrig’s Disease) or End-Stage Renal Disease (ESRD) are eligible for Medicare sooner. For more information, contact Social Security at 1-800-772-1213 or www.ssa.gov.
12. What if the hospital wants to discharge me too early?
If you are told you will be discharged from the hospital before you feel well enough to go home, you may file an appeal to Medicare’s Quality Improvement Organization (QIO), currently administered through Health Services Advisory Group, Inc. (HSAG). To file the appeal, you or a loved one may call 1-800-841-1602 by noon the day after you have been informed of the discharge plan. There is no charge for this service. Once the appeal is filed, you will neither be discharged nor billed for the time while your situation is investigated. HSAG will notify you and the hospital of the outcome. For more information, please call HICAP at 1-800-434-0222.
13. Who can help me understand Medicare and Long Term Care?
Your best resource for personal, up-to-date, and unbiased information is HICAP (Health Insurance Counseling and Advocacy Program) within California or SHIP (State Health Insurance Programs) outside of California. HICAP/SHIP is a free service funded through Medicare to provide health insurance counseling to current and future beneficiaries. In California, call HICAP at 1-800-434-0222 for an appointment.
14. What else can I do right now?
Health Insurance is very much in the news these days. You can be sure that the policies and procedures relating to Medicare and Long-Term Care will continue to change. It is important to keep up with the changes and how they will affect you and your loved ones.
The following is a list of things that you can do right now to best take care of yourself and your family:
♦ Educate yourself about what Medicare and Long-Term Care Insurance does and does not cover
♦ Discuss your potential health care needs as well as those of your family