Medicare is a federal program of Hospital and Medical Insurance that is available to eligible individuals who are over 65 or are permanently disabled and have received Social Security Disability Insurance payments for 2 years.   There are 3 benefits packages to Medicare, Part A (Hospital), Part B (Medical), and Part D (Prescription Drug) Insurance. In January 2006, Part D will begin. Click here for fact sheets and publications about Medicare Part D.   All amounts and figures reported are the official amounts and figures for the year 2007 - per Medicare

PART A - To be eligible for Medicare Part A, you must:

* be 65 or older and you or spouse paid into Social Security or Railroad Retirement Board for 40 or more quarters when worked
 

* Under 65 but have received Social Security Disability benefits for 24 months (or under 65 and have received Railroad Retirement Disability benefits for 24 months and meet SSA disability criteria)

* Under 65 but have End-Stage Renal Disease or ALS (Lou Gehrig's Disease)

* You or your spouse had Medicare-covered government employment

Generally participating in Part A insurance is free. There are co payments and deductibles, which are described below. But, there is no monthly premium for participating in Part A, unless you are 65 or older, not eligible for free Part A (because you have fewer than 40 "quarters" or work), and you are charged a monthly premium.

PART B - To be eligible for Medicare Part B, you must be enrolled in Part A.

*    Enrollment in Part B is neither required nor automatic.  The person must elect to enroll and can delay enrollment.  If enrollment is delayed, however, there is a penalty imposed which is added to the monthly premium and is based on the amount of delay.

To participate in Part B, the enrollee must pay a monthly premium of $93.50/month - for 2007 (unless beneficiary is eligible for the state to pay this for you - click here to find out more). This amount is usually deducted from the individuals' monthly Social Security check.

PART C- To be eligible for Medicare Part C or “Medicare Advantage” you must:

• You have both Part A and Part B and
• You live within the Plans Service Area
• You do not have End Stage Renal Disease

* 3 ways to Enroll in Part C:

1. Contact Medicare: 1-800-MEDICARE (1-800-633-4227 or 1877-486-2048 TTY)
2. Contact the Plan: The phone numbers are available for the different plans at www.medicare.gov and are also listed in the Medicare & You 2007 Handbook
3. Enroll Online: Go to www.medicare.gov and compare the Part C Plans and enroll directly through the website.

Part D - To be eligible for Medicare Part D, you must be entitled to Part A or enrolled in Part B.

* Enrollment in Part D is neither required nor automatic (unless the person is has full Medicaid).  The person must elect to enroll and can delay enrollment.  If enrollment is delayed, however, there is a penalty imposed which is added to the monthly premium and is based on the amount of delay. Persons on full Medicaid will be automatically enrolled into Medicare Part D. They can opt-out however, this is not advised since Medicaid will not cover the majority of drugs once Medicare Part D takes effect.

To participate in Part D, a person must purchase coverage from a private company. For more information about this, see below.

   Hospitalization     |    Skilled Nursing Facility   

 Home Health Care    |    Hospice
 

       Generally   ==>   The amount that Medicare pays and the amount that you pay depend on how long you are in the hospital during a given benefit period or hospitalization.

        Specifically ==>

                What is covered?

• Semi-private room and meals,
• General nursing services,
• Operating and recovery room costs,
• Intensive care,
• Prescriptions,
• Lab tests,
• X-rays, and
• All other necessary medical services and supplies.

What does it cost?

2007 – Medicare Part A Hospitalization
Days of Each Hospitalization	Deductible	Co-Payment
1-60	$992	$0
61-90	None additional ($992 already paid)	$248 Per Day
91 à 150 (if the beneficiary has not yet used his/her lifetime reserve days)	None additional ($992 already paid)	$496 Per Day
91 à (if the beneficiary has already used his/her lifetime reserve days)	None additional ($992 already paid)	Responsible for full daily rate for care at hospital – unless other supplemental insurance covers cost of hospitalization

Note that these are the costs per “episode of care”.

• Beneficiary's own doctor's bill is not covered under Part A. Residents and doctors of the hospital are covered under Part A.
• For Blood Transfusions while in Hospital, Medicare pays for all pints of blood after the 1st 3 pints and Beneficiary pays for the 1st 3 pints of blood that she requires during each benefit period/ each hospitalization - (unless beneficiary is eligible for full Medical Assistance from the state - click here to find out more)

What does Medicare Cover?  

Covers semi-private room and meals, skilled nursing services, rehabilitation, drugs, and medical supplies.

What does it Cost?

3. Home Health Care

     Full time home health care –

• Medicare pays nothing
• Beneficiary pays all or gets assistance from the state

     Part-Time or Intermittent Home Health Care

• For homebound persons who need intermittent coverage (less than 8 hours/day or less than 7 hours/day for periods of 21 days or less) of skilled nursing or therapy care
• Medicare pays entire cost of home health care - but only 80% of wheelchair, walker or other medical equipment,
• Beneficiary pays other 20% of wheelchair, walker or other medical equipment

1. Medicare pays for care with no deductibles but, doesn’t pay for drugs or inpatient respite care.
2. Beneficiary must pay copayment for drugs up to $5 and 5% of the Medicare amount for inpatient respite.
3. Covers 2 periods of 90 days and one subsequent period of 30 days
    

    What is covered?

            Part B has traditionally covered physician services (for a problem not for check-up or wellness visit), outpatient hospital services, durable medical equipment/supplies, ambulance, dialysis costs, home health, x-rays, lab tests, outpatient physical therapy, vaccines, etc.

        Preventative Health Coverage:

•         Preventative Health Coverage:

  • One time - "welcome to Medicare" physical exam if Part B started after 1/1/05 - must be within 6 months of when Part B starts
  • Annual mammography for women age 40 and over (no Part B deductible [$131])
  • Pap smear and pelvic exam every two years (if high risk, otherwise every other year) (no Part B deductible [$131])
  • Annual prostate screening for men age 50 and over
  • Colorectal cancer screening
  • Bone mass screenings every 2 years
  • Diabetes glucose monitoring and screening
  • Cardiovascular screening every five years
  • Glaucoma tests annually for people with high risk
  • Annual Flu shot
  • One pneumococal shot
  • Hepatitis B shot - Series of 3 Hepatitis B shots if medium to high risk

  Part B covered Outpatient Mental Health Services

  • Physician
  • Clinical psychologist
  • Clinical social worker
  • Clinical nurse specialist
  • Nurse practitioner
  • Physician Assistant

What is NOT covered?

• Outpatient Prescription drugs (to be covered by Part D)
• Routine office visits and wellness visits (except the “Welcome to Medicare” physical exam)
• Eye exams and eyeglasses (except following cataract surgery)
• Hearing exams and hearing aids
• Long Term Care
• Transportation

   What does it cost?

         Deductibles and Co-payments for Part B

• $131/year deductible for 2007 (unless beneficiary is eligible for full Medical Assistance or QMB coverage from the state - click here to find out more) and a monthly premium ($93.50 for 2007)
• Beneficiary pays 20% of Part B covered services. (unless beneficiary is eligible for full Medical Assistance or QMB coverage from the state - click here to find out more). Medicare pays the other 80% of the fee.
• For mental health services covered: Beneficiary pays 50% of doctor and professional charge and 20% of co-payment for facility charges

Part C Coverage

What is covered?

Beneficiary may choose to enroll in Medicare Advantage. What is covered is dependant upon which plan you choose. Plans cannot offer less than the basic Medicare Part A and B coverage but may offer more coverage.

What does it cost?

Usually, beneficiary must pay an extra monthly premium (on top of the Medicare Part B premium- $93.50)