The People's Guide

36th Edition 2015

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53 The People's Guide 2015 Medicare Can I Get Medicare? 1. Part A : Hospital Insurance You are automatically eligible for Medicare Part A free of charge if you are one of the following: • You are 65 or older and are eligible for Social Security retiree benefits based on your own or your spouse's employment • You are a federal employee who retired after 1982 and have enough quarters of coverage • You have been receiving Social Security Disability Income payments for 24 consecutive months • You are age 50 or older and are a disabled widow or widower who has received Social Security through your spouse for at least 2 years • You have end-stage kidney disease, regardless of your age (you still must have worked enough quarters, how- ever, even though you don't need to be 65.) • You have Lou Gerhig's disease. (You still must have worked enough quarters, even though you don't need to be 65.) People who are not automatically eligible for Medicare Part A may enroll voluntarily if you meet all of the following three re- quirements: • You are 65 or older • You are a U.S. citizen, or a legal alien who has resided in the U.S. continu- ously for at least five years • You purchase both Parts A and B of Medicare, or you purchase Part B only. You may not purchase Part A only. If you meet these three requirements for voluntary Part A, the amount of monthly premiums you will pay will depend upon how many work quarters you have on record with Social Security. If you have between 30 and 39 quarters, your monthly Part A premium is $234. If you have less than 30 quarters, your monthly Part A premium is $426. 2. Part B : Medical Insurance If you meet the eligibility guidelines for Part A, you will be eligible for Part B. The Part B monthly premium is $104.90. The premium is higher if your income is $85,000 or more for an individual and $170,000 or more for a married couple. If you have a low income and low re¬sources, the state may pay for your Medicare premiums under Medi-Cal or the Medicare Savings Program. What is Covered? Medicare does not cover all types of health care needs, nor is it free of cost. It does NOT cover custodial care in a nursing home or at home, dental care, eyeglasses, and hearing aids. For services that are covered by Medicare, you have to pay copayments. 1. Part A Coverage Medicare will pay for hospital care if a doc- tor has decided that you need inpa¬tient care and the hospital participates in Medicare You will pay a first day hospital deductible of $1,216 if you use days 1 through 60 in a benefit period. If you remain in the hospital for days 61 to 90, you pay $304 per day and Medicare pays the balance. If you need hospital care after the 90th day, you draw on 60 extra "reserve" days which are not renewable and can be used only once. During that period you pay $608 each day and Medicare pays the balance. 2. Skilled Nursing and Hospice Services After a three day prior hospitalization, Medicare pays for daily (five to seven days per week) skilled nursing and therapy ser- vices in a Medicare certified skilled nursing facility. Medicare pays for the first 20 days in full and days 21-100 on a copayment basis of $152 per day. Medicare pays for skilled nursing and therapy services in the home if you are homebound and meet other requirements. There are no copayments for home health services. Medicare hospice services are for persons who are terminally ill (patients must be recertified as "terminal" after 210 days of hospice care). 3. Part B Coverage Part B pays 80% of "allowable" charges for a variety of outpatient care,.You pay the remaining 20%, an annual deduct- ible of $147 and a 15% excess charge if the provider does not take "Medicare assignment." Doctors and other Part B providers who accept Medicare assignment agree to charge no more than the Medicare ap- proved charge. This means that you can be charged only for the 20% co-payment and any unpaid portion of the annual Part B deductible. Ask your provider if he or she will accept assignment. 4. Part D Coverage Part D pays for outpatient drug coverage. To obtain Part D coverage, you must enroll into a Medicare Part D drug plan. There are two types of Part D plans: PDPs that only provide Medicare drug coverage and MAPDs that provide Medicare Part A, B and D benefits. There is a standard Part D benefit package, however, not all Part D plans are the same. Each plan has its own drug formulary, cost sharing requirements and restrictions on coverage. 5. Medicare Advantage HMOs A Medicare Advantage HMO is a health insurance plan that enrolls Medicare ben- eficiaries who have both Medi-care Parts A and B. Medicare HMOs must provide the same benefits as original Medicare. Persons who have Med-icare end stage renal disease (kidney failure) cannot enroll into a Medicare HMO. When you join a Medicare HMO, you must use the HMO for all of your medical care, except for emergencies or urgent care when you are out of the HMO's service area. Medicare pays the HMO a fixed monthly amount for each enrollee. 6. Other Information Many people receive both Medicare and Medi-Cal. (see page 41 "Medi-Cal") People who have both programs do not have to pay Medicare's monthly premiums, de- ductibles, or co-payments when they see a provider that accepts Medi-Cal. If you have both Medicare and Medi- Cal, you should see health care providers that take both Medicare and Medi-Cal to avoid being charged any cost sharing amounts. If possible, show your insurance cards before you receive services. Medicare is a federal health insurance program . There are three parts to the program: "Part A" (hospital insurance), "Part B" (medical insurance), and "Part D " (prescription drug insurance). For general information call (800) 633 4227. Medicare

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