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| What Benefits Can You Expect From Medicare? |
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| Medicare is a federal health insurance program for people age 65 and older, people of any age with permanent kidney failure, and certain disabled people under age 65. Although Medicare will help you with many of your health insurance concerns after you turn 65, the truth is that Medicare coverage is limited. Under Medicare, you are still responsible for, among other costs, deductibles and co-payments as well as any charges that are greater than the Medicare approved amount. |
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| Once Medicare pays, you may still owe your doctor and the hospital more money. Depending on which state you live in, you might be able to receive benefits through an alternative to the original Medicare plan, and the alternative might offer you lower out-of-pocket costs. No matter which plan you choose, you are still in the Medicare program. |
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| What Are Your Options? |
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| This plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B health care (described below). You may go to any doctor, specialist, or hospital that accepts Medicare. You pay your share, and Medicare pays its share. Some things are not covered, like prescription drugs. (However, Congress has debated several measures that could extend Medicare to prescription drugs.) If you go to a provider who does not accept Medicare as the full payment, you will have to pay the difference between what Medicare pays and the total bill. |
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| These health care choices are available in some areas of the country. Choices that may be available in your area include Medicare Managed Care Plans, such as Health Maintenance Organizations, Preferred Provider Organizations, or Provider Sponsored Organizations. In addition, Private Fee-For-Service Plans and Medicare Medical Savings Account Plans may be available to you. In most of these managed plans, you can only go to doctors, specialists, or hospitals on the plan's list. Plans must cover all Medicare Part A and Part B health care. Some plans cover extras, like prescription drugs. Your costs may be lower than in the original Medicare plan. |
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| How does the Original Medicare Plan Work? |
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Part A for hospital insurance |
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Part B for medical insurance. |
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| helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care. Part A is financed through the FICA tax. |
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| If you plan to retire at age 65, you contact the Social Security Administration about three months before your 65th birthday. The Social Security Administration will enroll you in Medicare. If you're already receiving Social Security benefits when you turn 65, you'll be contacted by the Social Security Administration and automatically enrolled in Medicare Part A on your 65th birthday. You pay no premium or fee for Part A. |
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| Your coverage under Medicare is described in terms of a "benefit period." A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you've been out of the hospital or skilled nursing facility for 60 days in a row, or remain in a skilled nursing facility but do not receive skilled care there for 60 days in a row. |
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| Medicare doesn't pay for custodial care — that is, care that could be given by someone who isn't medically skilled, such as help with dressing, walking, or eating. However, if you're confined to your home and meet certain other conditions, Medicare Part A can pay the full approved cost of home health care visits from a Medicare-participating home health agency. No prior hospital stay is required, and there's no limit on the number of covered visits. Note, however, that coverage is for part-time or intermittent care only. Moreover, there's no coverage for services primarily to assist in daily living, as noted above. |
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| Table 1 shows services covered under Medicare Part A during any benefit period. As you can see, an illness or accident that requires a lengthy hospital stay or a number of benefit periods in one calendar year can be costly in terms of deductibles and co-payments. |
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| helps pay for doctors' services and many other medical services and supplies that aren't covered by Medicare Part A. These services are covered, no matter where you receive them — hospital, clinic, or home. Part B is optional. You're automatically enrolled in Part B when you become entitled to Part A. If you do not want Part B, you must opt out. There is a monthly premium — $54.00 per covered person in 2002 — and you will be billed unless you decline coverage. |
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| There's a $100 annual deductible before Medicare Part B begins paying for covered services. The $100 deductible must represent services or supplies covered by Medicare. It must also be based on the Medicare-approved amounts, not necessarily the actual charges billed by the physician or medical supplier. The Health Care Financing Agency sets the approved amount for physicians' services and publishes a national fee schedule. Medicare pays 80% of the approved amount after you've met the deductible. |
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| In addition to the 20% Medicare coinsurance, you pay for charges that exceed the amount approved by Medicare unless the doctor or supplier agrees to accept Medicare's approved amount as full payment. (In some states, doctors who accept Medicare are required to accept it as full payment.) Health care providers are not required to accept Medicare patients. |
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| Table 2 shows the payments for services under Part B, and your responsibility for deductibles and co-payments. The Medicare-approved rate for many doctors' services is below what many doctors charge. Unless the doctor explicitly agrees to accept Medicare as full payment, you must pay the difference between the fee and the Medicare-approved rate. |
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| Although Medicare pays for many of your health care needs after you turn 65, there are clear limits. Here is a sampling of what Medicare Parts A and B do not cover: |
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Care in a skilled nursing facility beyond 100 days per benefit period |
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Custodial care – probably the type of care most commonly required by those in a nursing home |
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Out-of-pocket prescription drugs |
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Medical tests for (and cost of) eyeglasses or hearing aids |
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Care received outside the United States |
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Cosmetic surgery |
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Routine eye care |
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Routine foot care |
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Most dental care and dentures |
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Orthopedic shoes |
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Routine or yearly physical exams |
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| The way to cover these limitations is through the purchase of Medigap insurance, which is sold by private insurance companies and designed to fill the gaps between Medicare benefits and the coverage you need and desire. |
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Table 1: Medicare Part A: Hospital Insurance – Covered Services Per Benefit Period
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| Table 2: Medicare Part B: Medical Insurance – Covered Services Per Calendar Year |
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| Part B covers portions of the following preventive services: |
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Bone mass measurements |
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Colorectal cancer screening |
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Diabetes monitoring |
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Mammogram screening |
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Pap smear and pelvic exam |
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Prostate cancer screening |
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Certain vaccinations |
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Ambulance services (limited). |
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Artificial limbs and eyes |
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Braces – arm, leg, back, and neck |
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Chiropractic services (limited) |
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Emergency care |
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Eyeglasses (limited) |
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Kidney dialysis and transplants |
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Medical supplies (limited) |
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Outpatient prescription drugs (very limited) |
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Preventive services (limited) |
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Prosthetic devices, including breast prosthesis |
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Services of practitioners, including clinical psychologists, social workers, and nurse practitioners |
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Transplants – heart, lung, and liver (limited) |
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X-rays and some other diagnostic tests |
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| For more information you can call 1-800-MEDICARE (1-800-633-4227) for more help, to order publications, and to talk with a Customer Service Representative. |
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