Medicare Benefits - Medicare Eligibility

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About Medicare

Q: What is Medicare?

A: Medicare is a health insurance program for:

People 65 years of age and older.
Certain younger people with disabilities.
People with End-Stage Renal Disease (people with permanent kidney failure who need dialysis or a transplant, sometimes called ESRD).

Q: What is the Original Medicare Plan?

A: The Original Medicare Plan is the traditional pay- per- visit arrangement. You can go to any doctor, hospital, or other health care provider who accepts Medicare. You must pay the deductible. Then Medicare pays its share, and you pay your share (coinsurance). The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Q: What is Part A (Hospital Insurance)?

A: Part A (Hospital Insurance) helps pay for care in hospitals and skilled nursing facilities, and for home health and hospice care. If you are eligible, Part A is premium-free, that is, you don’t pay a premium because you or your spouse paid Medicare taxes while you were working. Your Fiscal Intermediary* can answer your questions on what Part A services Medicare will pay for and how much will be paid.

Q: Who is eligible for premium- free Part A?

A: You are eligible for premium- free Part A (Hospital Insurance) if:

You are 65 or older. You are receiving or eligible for retirement benefits from Social Security or the Railroad Retirement Board, or
You are under 65. You have received Social Security disability benefits for 24 months, or
You are under 65. You have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
You or your spouse had Medicare- covered government employment, or
You are under 65 and have End- Stage Renal Disease.

If you don’t qualify for premium- free Part A, and you are 65 or older, you may be able to buy it. (Call your local Social Security Administration office or call 1-800-772-1213.)

Q: What is Part B (Medical Insurance)?

A: Part B (Medical Insurance) helps pay for doctors, outpatient hospital care and some other medical services that Part A doesn’t cover, such as the services of physical and occupational therapists. Part B covers all doctor services that are medically necessary. Beneficiaries may receive these services anywhere (a doctor’s office, clinic, nursing home, hospital, or at home). Your Medicare carrier can answer questions about Part B services and coverage.

Q: Who is eligible for Part B (Medical Insurance)?

A: You are automatically eligible for Part B if you are eligible for premium- free Part A. You are also eligible if you are a United States citizen or permanent resident age 65 or older. Part B costs $45.50* per month in 1999. You have a choice whether or not to keep Part B.

* New Part A and Part B premium, coinsurance, and deductible amounts will be available by January 1, 2000.

Q: If I choose to have Part B, how do I pay for it?

A: If you choose to have Part B, the monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement payment. Beneficiaries who do not receive any of the above payments are billed by Medicare every 3 months.

Q: If I didn’t take Part B when I was first eligible, when can I sign up?

A: If you didn’t take Part B when you were first eligible, you may be able to sign up during two enrollment periods:

General Enrollment Period: If you didn’t take Part B, you can only sign up during the general enrollment period, January 1 through March 31 of each year. Your Part B coverage is effective July 1. Your monthly Part B premium may be higher. The Part B premium increases 10% for each 12-month period that you could have had Part B but did not take it, unless you sign up during the Special Enrollment Period.

Special Enrollment Period: If you didn’t take Part B because you or your spouse currently work and have group health plan coverage through your current employer or union, you can sign up for Part B during the special enrollment period.

Under the special enrollment period, you can sign up at any time you are covered under the group plan. In addition, if the employemnt of group coverage health ends, you have eight months to sign up. The eight month period starts after the employment ends or the group health coverage ends, which ever comes first. Generally your monthly Part B premium is not increased when you sign up for Part B during the special enrollment period. Call the Social Security Administration at 1-800-772-1213.

Railroad retirees should call the Railroad Retirement Board to sign up for Part B.

Q: What are my out-of-pocket costs in the Original Medicare Plan?

A: The Original Medicare Plan pays for much of your health care, but not all of it. Your out- of- pocket costs for health care will include your monthly Part B premium. In addition, when you get health care services, you will also have to pay deductibles and coinsurance. Generally, you will pay for your outpatient prescription drugs. You also pay for routine physicals, custodial care, most dental care, dentures, routine foot care, hearing aids, and routine eye care. Physical therapy and occupational therapy services, except for those you get in hospital outpatient departments, have yearly limits on coverage. The Original Medicare Plan does pay for some preventive care, but not all of it.

Q: What do my out-of- pocket costs depend on in the Original Medicare Plan?

A: Your out- of- pocket costs depend on:

Whether your doctor accepts assignment.
How often you need health care.
What type of health care you need.
If you choose another Medicare health plan or purchase a Supplemental Insurance Policy, your out- of- pocket costs may also depend on:
Which Medicare health plan you choose.
What extra benefits are covered by the plan.
What your Supplemental Health Insurance

Q: What is Assignment?

A: In the Original Medicare Plan, doctors and other providers who accept assignment accept the amount Medicare approves for a particular service or supply as payment in full. (You are still responsible for any coinsurance amount.) Doctors who don’t accept assignment can require you to pay the full amount of the bill at the time of service. Medicare will then reimburse you for its share of the bill. Always ask your doctors and medical suppliers whether they accept assignment of Medicare claims. That could mean savings for you.

In certain situations, all doctors and medical suppliers are required to accept assignment. For instance, all doctors and qualified laboratories must accept assignment for clinical laboratory services covered by Medicare. Doctors also must accept assignment if you have a low- income and Medicaid pays your Medicare coinsurance.

Doctors and other health care providers who don’t accept assignment may not charge more than 15% over Medicare’s approved payment amount (the limiting charge). The limiting charge does not apply to services you get from doctors with whom you have a private contract, or for certain items and services, such as durable medical equipment, ambulance services, vaccinations, and anti-nausea drugs that are covered by Medicare. Call your Medicare Carrier* with questions.

For example, assume that your $100 Part B deductible has been paid for the year. You receive a medical service and the Medicareapproved payment amount for the service is $100.

If your doctor accepts assignment, the most you would pay is $20. If your doctor does not accept assignment, the most you would pay is $33.25 after Medicare pays its share of the bill. (Note: The approved amount is reduced by 5% if assignment is not accepted.)

References for Medicare Article

Centers for Medicare and Medicaid Services

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