The Health Care Financing Administration (HCFA) of the
U.S. Department of Health and Human Services administers
Medicare, the nation’s largest health insurance program.
Medicare (Title XVIII of the Social Security Act) covers people
who are 65 years and older and are citizens or permanent
residents of the United States, certain people who are
disabled, and people with End-Stage Renal Disease.
If you reach the age of 65 and are still working, you may end
up with health insurance through Medicare as well as through
your employer-sponsored health plan. In this case, your
employer-sponsored group health plan is the primary insurer
(pays first) and Medicare is the secondary insurer (pays after
the primary insurer pays).
Dialing for details
HCFA, which administers Medicaid as well as Medicare, provides
toll-free telephone numbers for information about your
health plan benefits, rights, and options. It also provides
information on the quality of managed care plans, Medigap
insurance, and the Medicare + Choice program.
Call 800-MEDICARE, or 800-633-4227 (877-486-2048
if you have a TDD or TTY) 8:00 a.m. to 4:30 p.m., local
time, weekdays. Talk to a customer service representative in
English or Spanish for:
- General information about Medicare and Medigap
insurance
- General information about Medicare health plan options
in your community
- Specific quality and satisfaction information about managed
care plans
- Telephone numbers for help with billing questions about
Medicare claims or other issues
After hours, use the automated options to
- Order Medicare & You handbooks or audiotapes in
English or Spanish
- Request updated information about health plans in
your area
- Hear recorded answers to frequently asked questions
Determining eligibility
If you’re eligible for Social Security retirement payments,
you’re usually eligible for Medicare coverage. You (or your
spouse) accumulate earnings credits on your annual Social
Security wages. One earnings credit equals one calendar quarter.
You need 40 quarters (ten years) of Social Security credit
to enroll in Medicare Part A without cost and in Part B for
$45.50 per month (1999 amount).
Federal government workers, nonprofit-organization employees,
and certain other workers may qualify with fewer than
40 quarters. You may also qualify if you have a disability or
a chronic kidney disease.
Check with your local Social Security office for more information
or to enroll in Medicare, or call the Social Security
Administration at 800-772-1213. (The TTY-TDD number
for the hearing- and speech-impaired is 800-325-0778.)
Automatic enrollment
If you’re under 65 and receive Social Security or Railroad
Retirement benefits, you’re automatically enrolled in
Medicare Part A and Part B. About three months before your
65th birthday, HCFA mails your Medicare card to you. If
you decide to reject Part B after you receive your Medicare
card, follow the instructions that accompany the card.
If you’re disabled, you are automatically enrolled in Part A
and Part B of Medicare beginning in your 25th month of disability.
HCFA mails your card to you about three months
before you are entitled to Medicare.
Part A and Part B each cover a different set of expenses. The
next two sections explain the benefits and costs for each part.
All dollar amounts shown are for 1999; figures may change
from year to year.
Original Medicare Plan Part A:
Covering hospitalization
Medicare’s Part A (hospital insurance) covers hospital services,
care in skilled nursing facilities, and home health and hospice
care services after you’re discharged from the hospital.
Members of Medicare Part A pay the following premiums:
- Eligible individuals (with 40 quarters of Social Security
coverage) pay no premium.
- Individuals with 30 to 39 quarters of Social Security
coverage pay $170 per month ($187.00 if you’re a late
enrollee).
- Ineligible individuals (with fewer than 30 quarters of
Social Security coverage) pay $309 per month ($339.90
if you’re a late enrollee).
You are a late enrollee if you enroll in Part B after your eligibility
period expires. The seven-month eligibility period
includes the three months before your 65th birthday, the
month of your 65th birthday, and the three months after the
month of your 65th birthday. The next opportunity for you
to enroll in Part B is during the general enrollment period,
from January 1 to March 31 of each year, with coverage
beginning July 1. If you wait more than 12 months after the
initial enrollment period, you pay an additional 10 percent
of the premium. This surcharge applies for a period that is
twice as long as enrollment was delayed.
Medicare determines benefits based on a benefit period. A
benefit period starts the day you’re admitted to a hospital or
skilled nursing facility. It ends after 60 consecutive days
(including the day you’re discharged) without hospital inpatient
or skilled nursing facility care. If you stay in a skilled
nursing facility, a benefit period ends after 60 consecutive
days without skilled nursing care.
In each benefit period, Medicare limits the number of days
it will help pay for inpatient hospital and skilled nursing facility
care. After you exceed the benefit period limit, you must
pay for all charges for each additional day of care. After you
end a benefit period, a new one begins, with renewed hospital
and skilled nursing facility benefits. The number of benefit
periods you can have is unlimited.
You are entitled to 60 nonrenewable reserve days. You may
use reserve days to help pay the bill if you are in the hospital
for more than 90 days in a benefit period.
Part A’s benefits for inpatient hospital insurance include:
- Days 1-60: You pay a deductible of $768 per benefit
period; Medicare pays the rest. Note: For days 21-100,
Part A also pays coinsurance of $96 a day in a skilled
nursing facility.
- Days 61-90: You pay coinsurance of $192 a day;
Medicare pays the rest.
- Days 91-150: You pay $384 a day for each nonrenewable,
lifetime reserve day; Medicare pays the rest. (You
have a maximum of 60 reserve days, and you may use
them only once.)
- Days 151 and beyond: You pay all costs; Medicare pays
nothing.
Check the Medicaid section later in this article for information
on additional sources of medical cost reimbursement.
When you enter the hospital for covered care, the hospital
must give you a document called An Important Message from
Medicare, which explains your rights as a Medicare hospital
patient. If you don’t get a copy, be sure to ask for one. Also
ask the billing department for assistance in getting the most
benefit from your health insurance coverage.
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