Health Care : Medicare

What is Medicare?

Medicare is a federally funded health insurance program for people who are age 65 or older, disabled, or have end-stage renal disease.

Medicare is not needs-based, which means that there are no income limits for Medicare eligibility.

Unlike Medicaid, Medicare is not comprehensive and does have copayments and deductibles.

See the Medicare.gov website for detailed information about this program.

How do I apply for Medicare?

You have choices about how to apply for Medicare.

1. You can apply for Medicare at your local Social Security office.

2. You can call Social Security to apply for Medicare at 1-800-772-1213.

3. You can use the online Medicare eligibility tool.

When should I apply for Medicare? What happens if I don’t apply when I am first eligible?

Most people become eligible when they turn 65 or they otherwise become disabled.

You should apply for Medicare as soon as you are eligible because there are penalties if you delay your enrollment.

If you do not apply for Part B when you are first eligible you will have higher premiums.

More information from the official U.S. Government site for people with Medicare -- Questions and Answers.

What do they mean by Medicare Parts?

Medicare has four parts. Not everyone is eligible for, or chooses to participate in, each part.

  • Part A is hospital insurance. Coverage and cost sharing vary with the length of the hospitalization.
  • Part B covers doctor visits, lab fees, medical equipment. Most services have a 20% cost sharing. There is a monthly premium for Part B of $88.50.
  • Part C, or Medicare Choice, is a managed care option that was established in the mid 1990's and has shrunk as managed care plans withdrew from Medicare.
  • Part D, the Medicare Prescription Dug Program, was created in 2004 in response to increasing drug costs and political pressure from senior citizens groups such as AARP. Part D began on January 1, 2006, and requires participants to select a Medicare drug program. Most people will have an additional monthly premium for Part D.

Do I have to pick a plan for my Medicare Part D services?

Yes, everyone who participates in Medicare Part D must pick a plan that will provide their services.

If you do not pick a plan, you will be assigned to a plan.

How should I pick a plan for Medicare Part D?

This is an important decision so you should consider all of your options and pick the plan that best fits your needs.

You should consider the following factors:

1. Cost - Each plan will have a different monthly premium. Look at the costs to make sure you can afford it.

2. Location - Different plans will use different pharmacies and mail in systems. Check to see which plans your local pharmacy accepts. You have to use a pharmacy that accepts your plan.

3. Drug Formulary (Drugs covered by the plan) - Medicare Part D plans do not have to cover every prescription drug, so you should check to see what plans cover the drugs you need. Plans can change their formulary so even if they cover your drugs now, they may change what they cover in the future.

4. Prior Authorization - What steps does the plan require to be approved before you can get your medications?

5. Administration - Does the Plan seem to be managed well? When you call them with questions, do they have prompt answers that help you understand how the plan works?

To compare Medicare Prescription Drug Plans, go to the Medicare Prescription Drug Plan Finder.

What does Part D cover?

Part D Plans are like other insurance plans that have co-payments and deductibles. Some plans cover more services than the basic Medicare plan.

What if I cannot afford to pay for a Part D Plan?

If you have limited income and resources, you can get help with the cost of a Part D plan.

About one-third of Medicare recipients will qualify for extra help.

If you qualify for extra help, Medicare will pay for almost all of your prescription drug costs.

You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 or visiting the Social Security website.

What if I disagree with a decision about my Medicare?

If you disagree with a decision about your Medicare, you have a right to appeal.

You have the right to appeal any decision about your Medicare services. This is true whether you are in the Original Medicare Plan, a Medicare managed care plan, or a Medicare prescription drug plan.

If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.

How do I appeal a Medicare decision?

The process for appealing a Medicare decision is listed on the back of your Medicare Explanation of Benefits (EOB).

Appeal forms are available at the federal Medicare web site.

What notices will Medicare send me?

Medicare will send you notices about your eligibility including when your eligibility begins and how much your premiums will be.

Medicare will also send you a Medicare card that you should show your medical providers whenever you get any services.

Medicare will also send you Explanations of Benefits (EOB) that tell you what Medicare has covered and what your costs should be.

Do I have a right to a hearing?

Yes, if you disagree with a decision about your Medicare, you have a right to appeal.

You have the right to appeal any decision about your Medicare services. This is true whether you are in the Original Medicare Plan, a Medicare managed care plan, or a Medicare prescription drug plan.

If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.

What kind of citizenship documentation do I need to apply for Medicare?

Unlike Medicaid, Medicare does not require you to provide documentation of U.S. citizenship.

What if I am eligible for both Medicaid and Medicare?

People who are eligible for both Medicaid and Medicare can get benefits from both programs.

You may qualify for complete dual coverage or for partial dual coverage.

Apply for both Medicaid and Medicare and ask your caseworker how the benefits will be coordinated between the two programs.

What if my doctor, hospital, or pharmacy sends me a bill for the costs that Medicare did not pay?

When any health care provider agrees to accept Medicare’s payment level for services, the provider agrees not to bill the patient for any services or costs not paid by Medicare and agrees not to charge the patient more than the allowable co-payment for Medicare services.

This is called “Balanced Billing” and in most situations it violates both state and federal laws.

If your medical provider tries to bill you more for Medicare services, contact your local legal aid office.

The only time that a medical provider can bill a Medicare recipient for any service is if the provider tells the patient in writing in advance that the service is not covered by Medicare and the patient agrees in writing in advance to pay the charges.

See also the Forms & Education tab in this section for more information.

The information in this site is not intended as legal advice.
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