It is important to realize that changes may occur in this area of law. This information is not intended to be legal advice regarding your particular problem, and it is not intended to replace the work of an attorney.
A booklet explaining current Medicare benefits called The Medicare Handbook is available from your nearest Social Security office or can be ordered by phone at (800) 772-1213.
Original Medicare has two parts: Hospital Insurance, called Part A, and Medical Insurance, called Part B. Medicare also offers a managed-care program called Medicare+Choice or Medicare Advantage, sometimes referred to as Part C. In 2006, a new Medicare program, Part D, began covering some prescription drug costs.
People 65 and older are eligible for Medicare Part A payments, if eligible for Social Security Retirement benefits or Railroad Retirement benefits. Most others who are not eligible for retirement benefits can purchase Part A coverage. The Social Security Administration recommends applying three to four months before you turn 65.
People under age 65 who have received Social Security disability benefits for more than two years are automatically eligible for Medicare Part A coverage. Even though they are automatically eligible, they still must apply for Medicare. Some people who are on kidney dialysis or who have had a kidney transplant also are automatically eligible.
People eligible for Medicare pay premiums, deductibles and co-payments. The Part B premium for most people is $96.40 per month (at the time of this writing in 2009). People with very high incomes pay a higher premium. The premium may be permanently higher if you wait until after you are 65 to enroll. If you are 65 or older but not automatically eligible for Part A Medicare benefits, the premium for hospital coverage ranges from $244 to $443 per month in 2009. Part A has a deductible of $1,068 per benefit period, defined later. There is a temporary penalty for late Part A enrollment. The cost of the premiums for prescription drug coverage varies greatly from plan to plan. So do co-payments, even within a single plan, depending on the medication needed. The drug plan premiums may be permanently higher for those who do not apply when first eligible.
Medicare Part A — Hospital Coverage
Part A of Medicare usually pays most of your hospital bill. It will pay for a semi-private room, medications while in the hospital, meals, regular nursing services, lab tests, x-rays, and medical equipment and supplies. Part A will also pay for the special care you get in an intensive care unit. It will not pay for an optional private room, private duty nurse or personal convenience items like a telephone or television.
Medicare has figured out how long people with different medical problems usually stay in hospitals. The hospitals are paid based upon these averages. How long you stay in the hospital should depend on the care that you need.
If you enter a hospital, you must pay the first $1,068 of charges in 2009, and Medicare pays all of the remaining costs for covered services while you are in the hospital for the first 60 days. Hardly anyone stays this long in the hospital. If you do, though, on the 61st through 90th days, you pay a co-payment of $267] per day in 2009, and Medicare pays the remaining amounts for covered services. If you stay in the hospital longer than 90 days, you begin using your only remaining hospital coverage, called lifetime reserve days. You only have 60 lifetime reserve days, and you pay $534 per day in 2009 as a co-payment. Once you have used all 60 lifetime reserve days, Medicare won't pay for hospital stays longer than 90 days per benefit period. A benefit period begins when you first enter the hospital. A benefit period ends when you have been out of the hospital, skilled nursing or rehabilitation services for 60 days in a row, including the day you were discharged.
Many people believe that Medicare will pay for nursing home care if they need it. Although Part A does pay for some nursing home care following a hospital stay of at least three days, very few people meet the strict requirements. In order for Medicare to pay, you must be in a nursing home that is licensed to provide skilled care and is approved by Medicare. You must be getting skilled care, such as physical therapy, at least five days per week.
If you meet all of the requirements, Medicare will cover up to 100 days of skilled care. After the first 20 days, there is a co-payment of $133.50 per day in 2009.
Medicare does not cover other kinds of care facilities.
Part A can pay for home health visits if you are confined to your home and need occasional skilled medical services. Part A also covers hospice services for people who are terminally ill and who are expected to live six months or less. (It can continue to pay if the person lives longer.)
Medicare Part B — Medical Insurance
Medicare Part B covers part of the cost for doctors’ services, outpatient hospital care, ambulance trips, laboratory and radiology services and medical equipment. It does not cover most routine examinations or routine foot care, most dental care or dentures, most hearing aids or glasses, or most prescription drugs.
Medicare managed care plans combine most of the coverage of Parts A and B, and may include low-cost prescriptions. Depending on the plan, those who want drug coverage may have to purchase an additional policy.
Medicare prescription drug plans are available to anyone eligible for other Medicare. They are all private plans, however, and individuals must apply for them directly from an insurance company. Evaluating which plan is best is difficult; people are encouraged to get free help from the Oregon Senior Health Insurance Benefits Assistance program, called SHIBA. To locate help in your area, call (800) 722-4134.
Lower income people may be able to have their Part B and Part D prescription premiums reduced through Social Security’s “extra help” program. Contact your Social Security office for information and applications.
Legal editor: Janay Haas, July 2009