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Effective: December 1, 2006 |
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04.40ar1 - Medicare (Archive) |
Archived: February 1, 2009 |
Medicare is a Federal health insurance program. The Social Security Administration (SSA) and Railroad Retirement Board (RRB) determine entitlement to Medicare, depending on the benefits the client is receiving. The Centers for Medicare and Medicaid Services (CMS) administers the program.
How are Medicare Services Provided?
The Buy-In is the process of having some or all of the client’s Medicare costs paid through federal and state-funded MA, if specific requirements are met.
Co-insurance is an insured person’s share of the cost of treatment. For example, if an insurance policy covers 80% of the cost, the co-insurance amount is 20%.
A deductible is the amount you must pay each year before a health care plan begins paying its portion of your medical bills.
Fee-for-service is a method of payment for health services. The medical provider bills and is paid for specific individual services.
Open enrollment is the time period a person may enroll in or change a health plan.
Note: Medicare has initial, general and special enrollment periods that vary from program to program.
A premium is an amount paid, usually monthly, for insurance services.
Medicare is a federal health insurance program. There are four main parts to the Medicare program:
l Part A – Hospitalization Insurance.
l Part B – Medical Insurance.
l Part C – Medicare Advantage.
l Part D - Prescription Drug Coverage.
Clients can be on all, some or one of the programs at a given time. All of the parts have premiums, co-insurance and deductibles which are subject to annual increases on January 1 of each year.
People who meet one of the following criteria may qualify for Medicare:
l Retired people age 65 and older who meet one of the following:
n Receive RSDI, SSI or Railroad Retirement income.
Note: Persons who do not file for retirement benefits at age 65 must still enroll in Medicare or risk having penalties assessed against their premiums.
n Are residents and citizens of the United States.
Note: These individuals must pay for Part A; late enrollment penalties apply. However, they may elect to only enroll in Part B.
n Are lawfully admitted to the U.S. for permanent residence (LPRs) residing continuously in the United States five years or more at the time of application.
Note: These individuals must pay for Part A; late enrollment penalties apply.
l People with 1619(a) or 1619(b) status who are receiving Social Security benefits.
l Disabled or blind people under age 65 after they have been continuously disabled for at least two years.
Exceptions: The following people who have a disability do not have a two year waiting period for Medicare:
m Eligible persons disabled by amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s Disease.
m People who are determined disabled by SSA and receive Social Security benefits before the age of 22 are eligible for Medicare at the age of 18 without a waiting period.
l People of all ages with End-Stage Renal Disease (ESRD) defined as permanent kidney failure requiring dialysis or a kidney transplant.
Note: Children or un-entitled spouses may only qualify if they are dependents of a person who has sufficient credits to qualify for Medicare coverage. Unlike all other Medicare programs, filing for benefits can take place after the death of the ESRD individual.
The following people do not qualify for Medicare:
l People under 65 who only receive survivors' benefits do not qualify for Medicare.
l SSI only recipients who are under 65 years old.
How are Medicare Services Provided?
People may choose how their Medicare services are provided. Once enrolled in Part A and/or Part B a person can choose:
l To stay with the Original Medicare Plan and pay the out-of-pocket expenses for Parts A and B and enroll in a stand-alone Part D prescription drug program.
n These benefits are fee-for-service.
n Beneficiaries may go to any provider that accepts Medicare.
l To enroll in a Medicare Advantage Health Plan (Part C) that covers Parts A, B and D.
l To purchase a Medigap (Medicare Supplement Insurance) policy (in lieu of enrolling in a health plan) to cover the ”r;gap” expenses not covered by Medicare such as the co-insurance and deductibles.
n These policies only pay for Medicare-covered services.
n The premiums for these policies depend on the plan purchased.
n Beneficiaries have six months from the date of their Medicare enrollment to select a plan. After the six months, plans can deny coverage due to health status.
Note: Medicare enrollees who purchased a Medigap policy with creditable drug coverage prior to January 1, 2006, can retain this coverage and not enroll in Part D. Medigap policies cannot offer drug coverage after this date.
l To remain covered under an employer provided health insurance plan with creditable drug coverage and enroll in Part A but not in Parts B or D. Once employer coverage ends, beneficiaries have a special enrollment period in which to enroll in Parts B and D without a penalty.
For people who are on the Original Medicare Plan and are fee-for-service, many doctors, other health care providers, and suppliers of health care equipment and supplies have agreed to accept assignment.
l Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Part B services and supplies.
l The person still pays the coinsurance and deductible amounts.
l If the person uses a provider that does not accept assignment:
n Fees charged can be up to 15% over the Medicare-approved cost for a service.
n The person may have to pay the entire charge at the time of service. Medicare will then reimburse the person for the Medicare-covered share of costs.
People needing more information about Medicare should visit the websites listed or call Medicare at the toll free number:
l www.SSA.gov.
l 1-800-MEDICARE (1-800-633-4227).
For more information about Medicare in this manual see:
Medicare and MN Health Care Programs.