Medicare

INTRODUCTION

Medicare is a federal health insurance program that helps pay the hospital and other medical expenses of people age 65 or older and certain disabled people. The program is funded by monthly premiums from the insured people and by taxes paid by employers and workers. The Social Security Administration and the Railroad Retirement Board local offices accept applications for Medicare and provide general information about the program.

There are two parts to the Medicare program. Part A, Basic Hospital Insurance, and Part B, Supplementary Medical Insurance. In general, Part A covers inpatient care in a hospital, skilled nursing home, or hospice that participates in the Medicare program and home health care provided through a home health agency that participates in the Medicare program. Almost all hospitals and a number of skilled nursing homes, hospices, and home health agencies participate in the Medicare program.

ELIGIBILITY

Part A
You will be eligible for Part A at no cost if you meet any of the following requirements:

1. You are 65 or older and you are receiving Social Security or Railroad Retirement benefits.

2. You are disabled and you have been receiving Social Security or Railroad Retirement disability benefits for at least 2 years.

3. You are the widow, widower, or child of a person described in item 2 above, and the Social Security Administration or Railroad Retirement Board has determined that you are disabled.

4. You are receiving Social Security or Railroad Retirement benefits and (a) you are on dialysis, or (b) a doctor has certified that you need a kidney transplant because of permanent kidney failure.

5. You are a federal civil service employee age 65 or older and you became eligible for federal retirement benefits after January 1, 1983.

6. You are a state or local government employee age 65 or older and you were hired after April 1, 1986.

If you do not fit in one of the categories above, and you are age 65 or older, you will be eligible for Part A, but you will have to pay monthly premiums.

Part B
You will be eligible for Part B if you are eligible for Part A and you pay a monthly premium of $54.00. This amount is current as of January 1, 2002. Premiums usually increase annually when Social Security benefits are raised. You do not have to be in Part B if you do not want to, but unless you inform the Social Security office, the Part B will automatically be taken out of your monthly Social Security check. You can also pay the premium in cash or by personal check.

ENROLLMENT
Anyone who is eligible for Part A at no cost is automatically enrolled and does not have to file an application at the Social Security office. You may decline coverage if you want. Even if you are not eligible for Part A at no cost, you may still enroll if you are a U.S. citizen or legal alien, age 65 or older, and you pay a Part A premium of $319 per month (for those who have less than 30 quarters of Medicare covered employment; Part A premiums are $175 per month for those who have 30-39 quarters of Medicare covered employment.) You must also enroll in Part B and pay the Part B monthly premium.

You should enroll in the period three months before you become eligible (usually your 65th birthday) to three months following the month you become eligible.

If you are not automatically enrolled and did not enroll during the time period described above, you can enroll during a general enrollment period. This is held January 1 through March 31 each year. Your protection will begin July 1 of the year you enroll. If you enroll for Part B during a general enrollment period, your monthly premium will be 10% higher than the basic premium for each 12 month period you could have had Part B but were not enrolled.

HOW PART A WORKS
Part A will pay your covered expenses for care in a hospital or skilled nursing home based on "benefit periods," also called "spells of illness." Your first benefit period will begin the first time you enter a hospital or skilled nursing home. After you leave the facility, at least 60 days must pass before a new benefit period may begin. There is no limit on the number of benefit periods you may have.

Part A also will pay your covered expenses for care in a hospice or for some home health care provided by a home health agency. There are no benefit periods for this type of care.

Hospital Care
Part A can cover up to 90 days of medically necessary hospital care for each benefit period. For the first 60 days you are in the hospital, you must pay the first $812 of covered expenses, and Part A will pay the rest. (However, you will not have to pay the first $812 of covered expenses again if you return to the hospital during the next 60 days.) For the next 30 days you are in the hospital, you must pay the first $203 of covered expenses each day, and Part A will pay the rest. (Amounts shown are current as of January 1, 2002.)

You have 60 lifetime reserve days. If 90 days have gone by and you are still in the hospital, you will have the option of using some of your lifetime reserve days. For each lifetime reserve day, you must pay the first $406 of covered expenses, and Part A will pay the rest. Once you use a lifetime reserve day, you will not get it back.

Covered expenses for care in a hospital are reasonable costs for medically necessary services and supplies, including: (1) semi-private room; (2) meals; (3) nursing care and related services; (4) use of hospital facilities; (5) drugs; (6) medical supplies; (7) appliances and equipment; (8) operating room and recovery room costs; and (9) other items and services normally provided by a hospital, like rehabilitation services, physical therapy, and speech therapy.

Skilled Nursing Home Care
Part A will cover up to 100 days of care in a skilled nursing home for each benefit period if all of the following requirements are met:

1. You are in a hospital at least 3 days in a row (not counting the day you leave) within the last 30 days before your transfer to the nursing home.

2. You are transferred to the nursing home because you require care for a condition that was treated in the hospital.

3. You are admitted to the nursing home within a short period of time, generally 30 days, after you leave the hospital.

4. A doctor certifies that you need, and you actually receive, skilled nursing or skilled rehabilitation services on a daily basis.

5. The Medicare Part A intermediary or the nursing home's utilization review committee approves your stay.

If you are eligible, Part A will pay all covered expenses for the first 20 days. For the next 80 days, you must pay the first $101.50 of covered expenses each day, and Part A will pay the rest. While there is a deductible for hospital care, there is not a deductible for skilled nursing home care. A nursing home cannot require a deposit from a resident who is eligible for Medicare to pay nursing home expenses. If you need nursing home care longer than 100 days, Medicare will not pay. You will be responsible for the full cost of the care.

Covered expenses for care in a skilled nursing home include: (1) semi-private room; (2) meals; (3) nursing care and related services; (4) drugs; (5) medical supplies; (6) appliances and equipment, like a wheelchair; and (7) other items and services normally provided by a skilled nursing home, like rehabilitation services, physical therapy, occupational therapy and speech therapy.

Hospice Care
A hospice is a public agency or private organization that is primarily engaged in providing pain relief, and symptom management and support services to terminally ill patients and support services to their families. Medicare Part A can halp pay for hospice care if all of the following three conditions are met:

(1) A doctor certifies that a patient is terminally ill.

(2) A patient chooses to receive care from a hospice instead of standard

Medicare benefits for the terminal illness, and

(3) Care is provided by a Medicare-certified hospice program.

Home Health Care
Both Part A and Part B Medicare help pay for home health care provided by a public or private home health agency. Covered home health services include part-time skilled nursing care; physical therapy and speech therapy. Occupational therapy and medical social services may also be covered if done under the direction of a qualified person and ordered by a physician. Services of a part-time home-health aid to care for the personal needs of a patient may also be covered. At the present time (1/1/02) there are no co-payments and deductibles for home health care services.

MEDICARE + CHOICE
Since its beginning in 1965, Medicare has provided a health insurance program in which all beneficiaries could expect the same level of health insurance coverage. In 1997, Congress passed the Balanced Budget Act which expands the options for Medicare coverage through a variety of managed care plans, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee for service plans and new mechanisms such as medical savings accounts (MSAs). These new options are called Medicare + Choice or Medicare Part C.

While these new choices are now available, Medicare beneficiaries retain the right to continue to receive health care as they have in the past under the traditional Medicare fee-for-service program. Beneficiaries will remain in their current Medicare plan unless they make a change to a Medicare + Choice plan. If a beneficiary is satisfied with the current Medicare health care coverage, he or she does not have to do anything to keep that coverage. To be eligible to enroll in a Medicare + Choice plan, an individual must be entitled to benefits under Part A and enrolled under Part B. Persons with end-stage kidney disease cannot enroll in a Medicare + Choice plan.

Medicare + Choice plans (except the MSAs) must provide coverage for the services currently available under Medicare Parts A and B. Some plans may offer benefits, such as prescription drug coverage, in addition to benefits under the traditional Medicare program for which no extra premium will be charged. Under some circumstances, plans may offer additional benefits for which a separate premium may be charged. Medicare + Choice plans may limit the beneficiary's choice of medical service providers such as doctors and hospitals. The coverage details of each plan must be considered carefully before deciding to make a change. Beneficiaries could enroll or disenroll at any time from a Medicare + Choice plan through the end of 2001. Beginning in 2002, beneficiaries are restricted to one change during January 1 June 30, 2002 and January 1 March 31 in subsequent years. A beneficiary who disenrolls from a Medicare + Choice plan can return to the traditional Medicare fee-for-service plan.

Beneficiaries should carefully review their coverage under their traditional Medicare program, Medicare supplement insurance plan, or any other health care coverage and compare it to the Medicare + Choice plans. Some plans may promise more generous benefits but at a higher cost and may also limit choice of medical care providers. No matter which health care option you choose, you are still in the Medicare program.

HOW PART B WORKS
Under Part B, you pay a deductible equal to the first $100 (effective January 1, 1997) of the Medicare-approved charges for covered expenses. Then, Part B will pay a co-payment percentage equal to 80% of the Medicare-approved charges for your covered expenses during the calendar year.

The Medicare-approved charge is usually less than the actual expense. Thus, depending on the payment method used by your care provider, you may have to pay more than 20% of the Medicare-approved charge. Please see the "How Claims Are Paid" Section below for an explanation of the Part B payment methods.

Medicare Part B can help pay for the following services and items: medical and surgical services, including anesthesia; diagnostic tests and procedures that are part of your treatment; radiology and pathology services by doctors while you are a hospital in-patient; X-rays; mammography every two years; services of a doctor's office nurse; drugs and biologicals that cannot be self-administered; transfusion of blood and blood components; physical therapy and speech pathology services; medical supplies such as surgical dressing, splints and casts; rental or purchase of durable medical equipment such as crutches, wheelchairs and blood pressure monitors; ambulance services and prosthetic devices.

Both Part A and Part B Medicare help pay for home health care provided by a public or private home health agency. Covered home health services include part-time skilled nursing care; physical therapy and speech therapy. Occupational therapy and medical social services may also be covered if done under the direction of a qualified person and ordered by a physician. Services of a part-time home-health aid to care for the personal needs of a patient may also be covered. At the present time (1/1/02) there are no co-payments and deductibles for home health care services.

EXPENSES NOT COVERED
Neither Part A nor Part B will pay for: (1) custodial care; (2) personal comfort items; (3) routine check-ups; (4) care in an intermediate nursing home; (5) full-time nursing care at home; (6) hearing aids and eyeglasses and the examinations for prescribing or fitting them; (7) drugs or medicines you buy with or without a doctor's prescription (as of 1/1/02) (8) private duty nurses; (9) expenses covered by employer group health plans, when the plan is the primary payor; or (10) services not reasonable or necessary as defined by Medicare; and (11) chiropractic services, cosmetic surgery, dental care, private rooms, or orthopedic shoes, with some exceptions.

HOW CLAIMS ARE PAID
You do not have to send in any bills for care you receive from any medical services provider under Medicare Part A or Part B. The provider must submit the claim to receive payment and Medicare will send its share of the cost directly to the provider. You will get a notice explaining what was paid by Medicare. If a provider fails to timely submit a bill for payment by Medicare, the provider cannot seek payment from you.

Payment is made two ways under Medicare Part B. The medical insurance payment can go directly to the doctor or medical service supplier if you and the other party agree to this. This payment method is called assignment. If the provider does not accept assignment, you may have the payment made directly to you and you will have to pay the doctor or care provider yourself.

Under the assignment method, Medicare then pays your doctor or supplier 80% of the approved charge (after subtracting any part of the $100 deductible you have not paid.) The advantage to this method is that the doctor or supplier, when accepting assignment, agrees to make the Medicare approved charge his/her total charge to you  even if the actual charge is higher. For example:

	Actual Medicare Charge	Approved Charge	Medicare Pays	You Pay
Doctor Accepts Assignment	$450	$400	$320 (80% of $400)	$80 (20% of $400
Doctor Doesn't Accept Assignment	$450	$320	$320 (80% of $400)	$130 ($450 - $400 + 80)

Most doctors and other medical service suppliers do not accept assignment. If your doctor or supplier does not agree to the assignment method, the medical insurance payment will then come to you directly and you will be responsible for payment of the difference between the actual charge and the Medicare approved charge, plus the 20% of the Medicare approved charge.

In case you have an opportunity to choose between the two payment plans, remember that only under the "payment to you" method can the doctor or supplier bill you for his/her actual charge, even if that charge exceeds Medicare's approved charge. If that happens, you must pay the difference between the actual charge and the approved charge. Whatever payment method you have under Part B, you still must pay the doctor or health service supplier directly the 20% of the approved charge (plus any unpaid part of the $100 deductible) as well as the difference between the approved and actual charges if assignment is not accepted. (If you have Medicare supplemental insurance, it may pay the 20% co-payment under Medicare Part B up to $5,000.) If a doctor does not accept assignment, the doctor is limited by the Medicare program as to the amount which can be charged for a service. The limiting charge is 115% of the Medicare established fee schedule amount for non-participating physicians. The difference between the "approved amount" and the "limiting charge" is the "balance billing amount."

Doctors and suppliers can sign agreements to become Medicare-participating doctors or suppliers. This means that they have agreed in advance to accept assignment on all Medicare claims. Doctors and suppliers are given the opportunity to sign participation agreements each year. The names and addresses of Medicare-participating doctors and suppliers are listed in the Medicare-Participating Physician/Supplier Directory. This directory can be obtained free of charge from your Medicare carrier, AETNA Insurance.

APPEALS
If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have the right to appeal the decision. The notice you receive from Medicare which tells you of the decision made on a claim will also tell you what appeal steps you can take. Following is a brief summary of the different Medicare appeals processes.

APPEALING DECISIONS BY PEER REVIEW ORGANIZATIONS (PROs)
Peer Review Organizations make decisions on the need for hospital care. Peer Review Organizations (PROs) are groups of practicing doctors and other health care professionals who are paid by the federal government to review the hospital care of Medicare patients. Each state has a PRO to help Medicare decide whether care is reasonable and necessary, is provided in the appropriate setting, and meets the standards of quality accepted by the medical profession. In Georgia, the Peer Review Organization is the Georgia Medical Care Foundation, 57 Executive Park South, Suite 200, Atlanta, Georgia 30329. Phone: (404) 982-0411.

When such standards are not me, PROs have the authority to deny payments. In addition, PROs respond to requests for review of hospital decisions or reconsideration of PRO decisions. They also investigate individual patient complaints about care received in a hospital. If you are admitted to a Medicare participating hospital, you will receive a document entitled "An Important Message From Medicare" which explains your rights as a hospital patient.

If you feel that you are improperly refused admission to a hospital or that you are forced to leave the hospital too soon, you may appeal such a decision as follows:

1. Pre-Admission Decision. If you are trying to enter a hospital for treatment, the hospital may tell you that the treatment will not be covered by Medicare. If so, you should request that the hospital give you a written explanation of its decision. If you disagree with a pre-admission decision, you can request in writing or by telephone that the PRO either review the hospital's decision or reconsider its own decision, as appropriate. The PRO must respond to your request within three working days if you send it to the PRO within three calendar days of the initial decision. Otherwise, the PRO will have 30 days to respond to your request, although the PRO must respond within 60 days of the initial decision.

2. Noncoverage Decision. If you are in a hospital and Medicare is covering your stay, the hospital may give you a "notice of noncoverage" telling you that your stay will no longer be covered by Medicare. If this happens, write down the date you receive the notice. If the hospital or your doctor gives you this information verbally, request that it be put in writing.

If you disagree with a notice of noncoverage and wish to remain in the hospital, you can appeal to the PRO. If the notice of noncoverage says that you no longer need continued stay in a hospital, you or your representative should call the PRO as soon as possible. The PRO has the next three working days in which to decide your appeal. If the PRO changes its initial decision, Part A will continue to pay for your hospital stay. If the PRO does not change its initial decision, the hospital may charge you for your stay starting the third calendar day after you receive the notice of noncoverage. Thus you may have to pay for some of your stay while the PRO decided your appeal.

If you disagree with the decision of a PRO, you can appeal by requesting a reconsideration. Then, if you disagree with the PRO's reconsideration decision and the amount in question is $200 or more, you can request a hearing by an Administrative Law Judge. Cases involving $2,000 or more can eventually be appealed to a federal court.

APPEALING ALL OTHER HOSPITAL INSURANCE DECISIONS (PART A)
Appeals of decisions on all other services covered under Medicare Part A are handled by Medicare intermediaries. An intermediary is a private insurance organization the federal government contracts with to make coverage and payment decisions under Part A. In Georgia, Blue Cross/Blue Shield makes most Part A coverage and payment decisions, although not in all cases. Their address is:

Blue Cross/Blue Shield
P.O. Box 9048
Columbus, Ga. 31908
Phone: (877) 567-3095

If you disagree with the intermediary's initial decision, you may request a reconsideration. The request can be submitted directly to the intermediary or through your Social Security office. If you disagree with the intermediary's reconsideration decision and the amount in question is $100 or more, you can request a hearing by an Administrative Law Judge. Cases involving $1,000 or more can eventually be appealed to a federal court.

APPEALING DECISIONS ON MEDICAL INSURANCE CLAIMS (PART B)
Under Medicare Part B, your doctor or your supplier submits the claim for payment. Medicare will send you an explanation of the decision made on the claim on a form called "Medicare Summary Notice" (or similar form). The form also explains how you can appeal denials or payment decisions with which you disagree, and gives the name, address, and State-wide toll-free number of the carrier which handles claims for services by doctors and other suppliers covered under Part B. In Georgia, the Medicare Part B carrier is Aetna Insurance Company and their address and phone are as follows:

Aetna Insurance Company
P.O. Box 3018
Savannah, Georgia 31402-3018
Toll-free call: 1-800-307-4830

If you disagree with the decision on your claim, you can ask the carrier to review it. Then, if you disagree with the carrier's written explanation of its review decision and the amount in question is $100 or more, you can request a hearing by the carrier. To reach the $100 amount, you can count other claims that have been reviewed within the past six months.

If you disagree with the carrier hearing decision and the amount in question is $500 or more, you are entitled to a hearing before an Administrative Law Judge. Cases involving $1,000 or more can eventually be appealed to a federal court.

RESOURCES AND LINKS
MEDICARE

1. For Medicare customer service, call 1-800-633-4227
(Hearing impaired call 1-800-255-0056)

2. For explanations and assistance with medicare bills, claims, legal assistance, supplemental insurance, evaluation of health insurance plans, and counseling, call HICARE (Health Insurance Counseling Assistance and Referral for the Elderly) at 1-800-669-8387 or (404) 463-3350. Or contact www.hicare.state.ga.us

3. For information about prescription assistance programs,
call 1-800-633-4227, for information about a Health Care Financing Administration program, or log on to www.medicare.gov.

4. For individualized legal questions, call the Georgia Senior Legal Hotline, at 1-888-257-9519 or e-mail at seniorlegalhotline@yahoo.com.

5. For general Medicare information, contact www.medicare.gov.

6. For general questions about Medicare, call the Aging Connection with the Atlanta Regional Commission at (404) 463-3333, or log on to

sept 25, 2006