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Medicare
The purpose of this fact sheet to help a person with disability
plan ahead and prepare for Medicare, understand its services, how
to access the services, and how billing is handled.
MEDICARE-DEFINITION
Medicare is a federal health insurance program that covers the
cost of certain basic medical services for people 65 and older
and some people with disabilities or endstage kidney failure. Medicare
requires that you be a U.S. citizen or have a resident visa and
have lived in the U.S. for five consecutive years. For those with
disabilities, you also have to have a work history and be determined
to be disabled by Social Security Disability Insurance (SSDI) for
a period of 29 months or have kidney failure.
The 29 months is measured from the official date of onset of disability
as determined by Social Security, which may not coincide with your
last date of employment. Your approval letter from Social Security
includes the information that describes your date of disability.
Enrollment in Medicare for people with SSDI approved disabilities
is automatic. You will receive a notice about 3 months in advance
of your enrollment date, eg, 3 months before you reach your 29th
month of disability. When your enrollment date is reached, you
will receive a red, white and blue colored enrollment card from
the Center for Medicare and Medicaid Services, which oversees the
Medicare program.
It is important to review your current insurance
upon receipt of the 3 month advance notice because there is no
prescription coverage with Medicare and Federal Law prohibits you
from buying new individual insurance after you become Medicare
eligible. In addition, if you successfully appealed a denial of
Social Security benefits and are going to receive retroactive benefits,
you may not receive a 3 month advance notice because you are eligible
for Medicare sooner than anticipated.
We suggest you contact the Advocacy Unit at GMHC to review
your options when you receive the 3 month notice or if
you have filed an appeal of a Social Security denial.
While enrollment in Medicare Part A is automatic, you have the
option to decline the enrollment in Part B. However, if you decline
enrollment in Medicare when it is first offered, you may have to
pay a penalty for late enrollment in Medicare Part B. More information
about Part A and Part B is in the next section of this fact sheet.
WHAT DOES MEDICARE COVER?
Medicare is divided into two basic categories of services, Part
A and Part B. Part A covers inpatient hospital or skilled nursing
facility, home health care and hospice. Part B covers doctors services,
durable medical equipment, x-rays and lab services, and outpatient
services.
Please note: Medicare does not cover
annual physical exams, routine dental or vision care, custodial
long term care, or prescription drugs. However, Medicare will start
offering prescription drug coverage on January 1, 2006. Starting
this fall, persons with Medicare will be receiving mail with information
about choosing a Medicare drug plan. If you have both Medicare
and Medicaid, Medicaid will not cover your prescriptions starting
January 1, 2006. You will have to switch to the Medicare drug benefit.
If you have Medicare, please contact the Advocacy Unit for assistance
with enrolling in the Medicare drug benefit.
HOW MUCH DOES MEDICARE COST?
Medicare Part A is free of charge, except you will have to pay
a $912 (year 2005) hospital deductible for each Medicare period
of stay, and a daily copayment if you stay in the hospital more
than 60 days.
Medicare Part B has a monthly premium of $78.20 (year 2005), a
deductible of $100 per calendar year and pays 80% of the Medicare
approved fee for doctor's services. You or other insurance you
may have would be responsible to pay the remaining 20%, if the
doctor does not accept assignment.
The Part B premium is deducted from your monthly SSDI check. For
those on limited income, there are government programs that could
help pay the monthly premium, deductible, or the copayments. Please
contact the GMHC Advocacy Unit to learn more about these programs.
HOW DO I PAY THE DOCTOR?
The doctor may accept assignment, which means that the doctor
will accept the payment from Medicare as full payment. Doctors
who do not accept assignment can surcharge 5% over the Medicare
approved fee. This would mean that you and perhaps secondary health
insurance (if you have additional insurance) are responsible for
the 20% payment of the approved Medicare fee, plus the additional
5% that the doctor can charge.
For example, the doctor bills $105. The Medicare approved fee
is $100 for this service. If the doctor accepts assignment, Medicare
would pay $80 (80% of the approved fee) and the doctor would accept
the $80 as full payment. If the doctor does not accept assignment,
then Medicare would pay its $80 portion and you would have to pay
$25. ($20 plus the $5 that the doctor can surcharge.) As this example
illustrates, there is no cost to you when the doctor accepts assignment.
It is strongly recommended that you speak with your doctor to see
if the doctor will accept assignment.
USING MEDICARE
Medicare can be used in any medical facility or doctor's office
that accepts Medicare. It is advisable to check with the doctor
or medical facility or laboratory before receiving services to
assure that they accept Medicare. When you go to the provider's
office or facility, you will need to show them your Medicare card
so that they will process your account billing through Medicare.
In addition, any other health insurance coverage you may have should
be disclosed to the the provider.
MEDICARE OPTIONS
Medicare is available to use as a fee for service plan, which
means that you can go to any Medicare accepting doctor or facility
in the United States or Puerto Rico. Medicare services are also
available as an HMO, Health Maintenance Organization, which is
where private insurance companies offer Medicare benefits and services
through a limited network of doctors and hospitals. In addition,
there are Medigap health plans which provide some of the services
that Medicare does not cover. Medigap health plans, sometimes called
supplemental plans, charge a fee for their services.
IS THERE ANYTHING ELSE I NEED TO CONSIDER?
Yes. Some things to think about are:
- What if I have Medicaid? How does that work with Medicare?
- What if I have ADAP or Private Insurance?
- What can I do about my prescriptions when I am on Medicare?
- What happens if I return to work?
- What are the advantages of Medicare HMO's and Medigap policies?
Are there any disadvantages?
These are very important questions that could impact your health
care. A consultation with a GMHC Advocate would be an excellent
way to find out the answers. In addition, the answers may vary
depending on your individual circumstances.
**The Client Advocacy Unit at GMHC is available to assist
you. For more information, please call our Helpline: 212/367-1125,
Wednesday 2:00 to 5:30 pm. Walk-in services are available Monday
through Thursday, 10:00 am to 1 pm.
Revised 3/05
© 2005 Gay Men's Health Crisis
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