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Top Ten HICAP Medicare Questions
- What is Medicare?
- What is the difference between Medicare and MediCal?
- What does Medicare cover?
- Are there services Medicare does not cover?
- Who is eligible for Medicare?
- How do I signup for Medicare?
- When I enrolled in Medicare part A, I did not sign up for Part B. Is that coverage still available to me on the same terms?
- If I am not entitled to Medicare based on my employment, or the employment of my spouse, can I buy the coverage?
- Are there different health care systems Medicare beneficiaries can use to get their Medicare benefits?
1. What is Medicare?
Medicare is a federal health insurance program established in 1965 for individuals aged 65 or older, and anyone of any age with certain disabilities or permanent kidney failure. It is administered by the Center for Medicare Services (CMS) of the U.S. Department of Health and Human Services. Local Social Security Administration offices take applications for Medicare entitlement and provide information about the program.
Nationally, Medicare covers approximately 40 million persons, of whom about 3 million are disabled and nearly 200,000 are end-stage renal disease patients.
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2. What is the difference between Medicare and Medicaid (Medi-Cal in California)?
Medicare is a federal health insurance program for older and disabled persons, regardless of income and assets. Medicaid, on the other hand, is a medical assistance program jointly financed by the State and Federal governments for eligible low-income individuals. Medicaid covers health care expenses for all recipients of Aid to Families with Dependent Children (AFDC), and most states also cover the needy, elderly, blind, and disabled who receive cash assistance under the Supplemental Security Income (SSI) program. Medicaid also is extended to certain infants and low-income pregnant women and, at the option of the state, other low-income individuals with medical bills who qualify as categorically or medically needy.
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3. What does Medicare cover?
Medicare has two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). They are commonly called Part A and Part B because Medicare hospital insurance coverage is described in Part A, and medical insurance coverage in Part B of Title XVIII of the Social Security Act. Part A helps pay for inpatient care in a hospital or skilled nursing facility, or for care from a home health agency or hospice. If you are admitted to a hospital, Medicare provides coverage for a semi-private room, meals, regular nursing services, operating and recovery room costs, intensive care, drugs, lab tests, X-rays, and all other medically necessary services and supplies. Covered services in a skilled nursing facility include a semi-private room, meals, regular nursing services, rehabilitation services, drugs, and medical supplies and appliances.
Part B helps pay for limited physician services, outpatient hospital care, clinical laboratory tests, and various other medical services and supplies, including durable medical equipment. Physician services are covered any where you receive them in the U.S. Other covered services include surgical, diagnostic tests and X-rays that are part of treatment, medical supplies furnished in a doctor's office, and drugs which cannot be self-administered, but are part of the treatment plan. Medicare pays only for care that it determines is medically necessary.
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4. Are there services Medicare does not cover?
While Medicare helps pay a large portion of your medical expenses, there are various health care services and products for which Medicare will not pay. These generally include custodial care; eye-glasses, hearing aids, and examinations to prescribe or fit them; a telephone, TV, or radio in your hospital room; and most outpatient prescription drugs and patient medicines. Medicare also does not pay for cosmetic surgery, most immunizations, dental care, routine foot care, and routine physical checkups. Although some personal care services (for example: bathing assistance, eating assistance, etc.) can be covered as part of any skilled care, they are never covered alone except under the hospice benefit.
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5. Who is eligible for Medicare?
Generally, individuals age 65 and over can get Part A benefits if they can establish their eligibility for monthly Social Security or Railroad Retirement benefits on their own or their spouse's work record. In addition, certain government employees whose work has been covered for Medicare purposes, and their spouses, can also have Part A. In rare cases, involving individuals who became age 65 in 1974 or earlier, Part A may be available if they meet certain United States residence and citizenship or legal alien requirements.
Part A is also available to most individuals with permanent kidney failure, those who have been entitled to Social Security disability benefits or Railroad Retirement disability benefits for more than 24 months, and to certain disabled government employees whose work has been covered for Medicare purposes. Any person who is eligible for Part A is also eligible to enroll in Part B.
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6. How do I sign up for Medicare?
If you are already getting Social Security or Railroad Retirement benefit payments when you turn 65, you will automatically get a Medicare card in the mail. The card will usually show that you are entitled to both Part A and Part B and indicate the beginning dates of your entitlement to each. If you do not want Part B, you can refuse it by following the instructions that come with the card. If you are not receiving Social Security or Railroad retirement benefits when you turn 65, you may have to apply for Medicare coverage. Check with any Social Security Administration office to see if you are able to get Medicare under the Social Security system or based on Medicare covered government employment; check with the Railroad Retirement office if you are able to get Medicare under the Railroad Retirement system. If you must file an application for Medicare, you should do so during your initial seven-month enrollment period. That period starts three months before the month you first meet the requirements for Medicare.
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7. When I enrolled in Medicare Part A, I did not sign up for Part B. Is that coverage still available to me on the same terms?
You may still enroll in Part B during the annual general enrollment period from January 1 to March 31, and your coverage will begin on July 1 of the year you enroll. Your monthly premium will likely be higher than it would have been had you enrolled in Part B when you enrolled in Part A. Generally, if you defer your enrollment in Part B, you must pay a monthly premium surcharge. The surcharge is 10 percent for each 12-month period in which you could have been enrolled but were not. The surcharge generally does not apply if you delayed enrolling in Part B because you were covered by an employer health plan based on your (or your spouse's) current employment once you first became eligible for Medicare. In that case, you would be allowed to enroll in Part B during a special 7-month enrollment period. The period begins with the month the employer group health plan ends, or with the month the employment on which it is based ends, whichever is earlier. In the case of certain disability beneficiaries, the special period begins when Medicare replaces the employer group health plan as the primary payer of the beneficiary's covered medical services.
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8. If I am not entitled to Medicare based on my employment, or the employment of my spouse, can I buy the coverage?
Individuals age 65 or over who are United States residents and either United States citizens, or aliens who have been lawfully admitted for permanent residence and have resided in the United States for at least five years at the time of filing, can purchase both Part A and Part B, or just Part B.
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9. Are there different health care systems Medicare beneficiaries can use to get their Medicare benefits?
Yes. You can receive services covered by Medicare either through the traditional fee-for-service (pay-as-you-go) delivery system or through coordinated care plans such as health maintenance organizations (HMOs) and competitive medical plans (CMPs), which have contracts with Medicare.
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