Medicare

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Medicare is the federal health insurance program that provides health benefits to people who are 65 years old and to people with disabilities.

Contents

Frequently Asked Questions

Who is eligible for Medicare?

If you meet the following requirements, you are eligible for free Medicare Part A but must purchase Medicare Part B:

  • You are age 65 or older and eligible for Social Security or Railroad Retirement benefits; or
  • You are age 65 or older and the spouse or former spouse of someone who receives Social Security or Railroad Retirement Benefits; or
  • You have received Social Security Disability (SSDI) benefits for at least two years (24 months); or
  • You have Amyotrophic Lateral Sclerosis (ALS), also know as Lou Gehrig's disease; or
  • You have end-stage renal (kidney) disease.

People who do not meet the guidelines listed above are eligible for Medicare if they are:

  • 65 years of age or older; and
  • United States citizens or legal permanent residents who have lived in the United States continuously for at least five years.

These individuals can purchase both Parts A and B of Medicare or purchase Part B only.

What does Medicare cover?

Part A

Part A helps pay for four kinds of medical care:

In-patient Hospital Care

  • Medicare covers up to 90 days of hospital services in each "benefit period," and an additional 60 "lifetime reserve" days that can be used only once.
  • A "benefit period" begins when you are admitted to the hospital, and ends when you have been out of the hospital or have not received skilled care in a nursing facility for 60 consecutive days.

In 2005, for days 1-60, you pay a $912 deductible. For days 61-90, you pay a co-payment of $228 per day. For each "lifetime reserve" day 91-150, you pay a co-payment of $456 per day.

Skilled Care in a Skilled Nursing Facility

  • Medicare provides up to 100 days of daily skilled nursing care, after a three-day prior hospitalization, in each benefit period.
  • In 2005, Medicare fully covers the first 20 days at no charge to you. For days 21-100, you pay a co-payment of $114 per day. There is no Medicare coverage after the 100th day in any specific benefit period.

Home Health Care

  • Medicare covers home health visits, if you meet all of the following conditions:
    • You are considered "homebound," meaning it takes considerable effort for you to leave your home;
    • You require skilled nursing services or skilled therapy services on an intermittent or part time basis;
    • The services are provided by a Medicare certified home health agency;
    • Your doctor has prepared a plan of care.

Hospice Care

Medicare will pay for an approved hospice program if a doctor certifies that the patient is terminally ill (expected to have less than six months to live). The patient chooses the hospice benefit over the standard Medicare benefit. The goal of hospice is to care for the patient and his family rather than treating the illness.

Part B

Part B Medical Insurance helps pay for the following services:

  • physician services
  • rehabilitation therapy services
  • outpatient hospital services
  • ambulance services
  • diagnostic and laboratory tests
  • mental health services
  • durable medical equipment

When you use Medicare Part B services, you are responsible for a $110 annual deductible and Medicare co-payments.

What are the premium costs for Medicare Part A and Part B?

Medicare Part A is free if you are eligible for Social Security retirement or disability benefits. People who are not eligible for Social Security benefits must pay a monthly premium for Part A coverage. The amount of the premium is based on the number of Social Security quarters they have earned. Persons who have 30-39 quarters will pay $206 per month in 2005. Persons who have fewer than 30 quarters will pay $375 per month. All Medicare beneficiaries pay for Part B coverage. In 2005, the Part B premium is $78.20 per month.

How do I use Medicare?
  • Use medical providers who are listed as a Medicare contracted provider.
  • Present your Medicare card to your health care provider at the time you receive services.
  • All Medicare providers are required to submit claims for their services to Medicare on your behalf.
  • Always ask your provider if Medicare covers the service and if she/he will accept
  • A provider who accepts a Medicare assignment agrees to accept the Medicare approved charge for the service as payment in full.
  • Going to providers who accept Medicare assignment will save you money by limiting the amount you pay the provider to just the 20% co-payment of the Medicare-approved charge.
  • If your health care provider does not accept assignments, you will have to pay more than your 20% co-payment. This extra charge is generally an additional 15% above the Medicare approved amount.
  • If Medicare or your Medicare HMO has denied payment of a claim or service, you have the right to appeal. If you are a Los Angeles County resident, Contact the Center for Health Care Rights for assistance.
What if I have health insurance through my employer?
  • If you work beyond age 65 for an employer who has 20 or more employees, the employer must offer you the same insurance it offers younger workers. You may either accept or reject the Employer Group Health Plan (EGHP).
  • If you keep your employer health plan as your primary healthcare coverage, you can delay your enrollment in Medicare Part B until the date of your retirement. You then have an eight-month period in which to join Medicare without a penalty.
  • If you keep your employer plan and enroll in Medicare, the employer plan will be your primary healthcare coverage and Medicare will be the secondary payer.
  • If you drop the employer plan and enroll in Medicare, Medicare will be the primary and only payer. In this case, the employer is not permitted to offer you a Medicare Supplemental Insurance policy.
How Can You Close Some of the Gaps in Medicare Coverage?

There are healthcare expenses not covered by Medicare, such as prescription drugs, vision care, dental services and custodial nursing home care. In addition, Medicare has co-payments and deductibles. Health insurance retiree benefits provided by a former employer may cover some of these gaps. In addition, you may want to consider:

  • Joining a Medicare Health Maintenance Organization (HMO); or
  • Purchasing private Medicare Supplemental Insurance (a Medigap); or
  • Applying for Medi-Cal, a program for low income Medicare beneficiaries.

For more detailed information on any of the above programs and other Medicare-related issues, contact your local Social Security Office and ask for the local HICAP or Medicare Advocacy Program, or call 1-800-434-0222 or 1-800-510-2020 (California State calls only).

How do I apply for Medicare?

  • Local Social Security offices are responsible for processing Medicare applications.
  • You will generally apply for Medicare during your initial enrollment period. This seven-month period begins three months before your 65th birthday and continues for three months after.
  • If you miss your initial enrollment period, you can apply for Medicare during the general enrollment period. This period occurs during January through March of each year. The Medicare benefits are effective beginning July 1 of the same year. In this case, there may be a premium penalty assessed for late enrollment.
  • Individuals 65 years or older who continue to work and are covered by an employer group health plan may delay their enrollment in Medicare.
  • Persons who are eligible for Social Security disability benefits do not have to apply for Medicare. They are notified that they are eligible for Medicare shortly after completing the 24-month waiting period.
  • Application Process
    1. You can make an appointment to apply for benefits on the telephone or in person at your local Social Security office. (Social Security Administration Office 1-800-772-1213).
    2. Have all your papers ready for the appointment and fill out the application with the SSI representative
    3. You will receive your approval letter and Medicare card by mail. You can use the card to access services.
    4. On your Medicare approved letter, you can find your contact office information. If you move, get a change in income, or take a lengthy trip, you have to contact Social Security office to report.
    5. If you have any questions, please contact to Korean Resource Center.
  • Documents that may be required
    • Copies of birth certificates or proof of immigration status
    • Social Security Card
    • Proof of Income (such as a paycheck, letter from an employer indicating the amount and frequency of pay, copy of federal income tax 1040 form), Resources or Assets (such as most recent bank statement, car registration)

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