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J 1 WHAT i£ f*epiCARe? CMS Librarv j C2-07-13 ' | 7500 Securll I ! Baltimore, ? It's the federal government's health insurance program for people age 65 or older and for many people with disabilities. m r i' 1 1 1 Medicare has % parts: 1^ 1 HOSPITAL iHSUPAHee (PART A) Money for this part of Medicare SECURITY comes out of "Social Security' (FICA) taxes deducted from workers' pay. Employers also contribute. c M EPICAL INSURANCE (PAP-T 6) You pay a monthly premium if you enroll in this part of Medicare. The % parts cover different types of care and have different enrollment procedures. ASCRIPTOGRAPHICBOOKLETbyCHANNINGL.BETECO.,INC.,South Deerfield, MA01373U.S.A. © 1991 Allrightsreserved. LithographedinUSA 1992Edition 38190A-1-92 Toreorderphone800-628-7733andrequestbookletnumber38190. ra.* WHO'S euciBte fop- Eligibility for the % parte of Medicare varies: HOSPITAL INSURANCE (PART A) People age 65 or older are eligible if: • they're getting - or are entitled to - Social Security or railroad retirement benefits • they've worked long enough for the federal, state or local government. People under age 65 may be eligible if they're disabled or have kidney disease. MEPICAI INSURANCE (PART 6) Nearly everyone age 65 or older is eligible. Those who qualify for Hospital nsurance before age 65 are eligible, too. Over 34 million Americans are enrolled in Medicare/ Learn more... 3 hospital insupAHce (PAPT A) helps pay for: HOSPITAL CApe HUP6IH6 Op- Up to 90 days per benefit REHABILITATIVE CAPE period* are covered: (in a skilled nursing facility) • FIRST 60 DAYS - Hospital After you have a hospital stay of insurance pays all covered at least 3 days and meet certain costs after the first $652 (you other conditions, up to 100 days pay this amount once per per benefit period* are covered: benefit period, no matter how • FIRST 20 DAYS - Hospital many times you're admitted Insurance pays all covered to the hospital) costs • NEXT 30 DAYS - Hospital • NEXT 80 DAYS - Hospital Insurance pays all covered Insurance pays all covered costs beyond $163 a day. costs beyond $81.50 a day. There is no limit to the number of 90-day benefit periods you can have. wepe ape aiso 60 "P€SepV£" PAYS of covered hospital care for which Hospital Insurance pays all covered costs beyond $326 a day. (Unlike the 90 days per benefit period, reserve days cannot be replaced after use.) * A benefit period begins when you enter the hospital. It ends when you have been out of the hospital and have not received skilled care in another facility for 60 days in a row. HOME HtAVTH Hospiee cap£ If you need skilled nursing care Hospital Insurance pays or therapy in your home, Hospital covered costs for 210 days Insurance pays the approved cost (more if the patient is recertified of covered services, including: as terminally ill). Outpatient drugs and respite care are • part-time skilled nursing or home health aide care partially covered. • physical, speech and occupational therapy • medical social services • medical supplies. PCSTfUCTIOflS APPtV to Hospital Insurance: you must receive youp- caps CApe FROM A MUST Be APPPOV6P ^PARTICIPATING" by a Peer Review Organization FACIUTY or Utilization Review Committee or agency. Before receiving (for hospital and skilled nursing care in a hospital or other facility facility care). These groups help or at home, make sure that the Medicare decide if care is health-care provider participates "reasonable and necessary." in Medicare (see page 10). Care must also be approved by the Medicare intermediary. This organization handles Medicare Medioare- Hospital Insurance claims. partioipa+ing 6 HOW PO SI6H UP FOIL I HOSPITAL That depends on your retirement status and other factors. you uu Be bhpouxp YOU SHOULP CONTACT AUTOMAT1CAUY social secuprry if you're getting Social Security 3 months before you turn or railroad retirement benefits 65 if you: when you turn 65. You'll be • plan to take Social Security mailed information 2 or 3 - or to keep working months before your 65th • are a government employee birthday. or retiree who's eligible for If you're under 65 and getting Medicare. disability benefits, you'll get information about 3 months Contact Social Security right away before you qualify for if: Medicare. • you're a disabled widow or widower between ages 50 and 65, but not getting Social Security benefits • you or someone in your family has permanent kidney failure (and is not already getting Medicare). f*£0iCAt insurance COVERAGE (PART B) mepical insurance has a yearly "pepuctible" of $100. This means that you have to pay $100 toward covered costs each year. Then Medical Insurance will pay 80% of Medicare's approved fee for: PHYSICIAN'S SERVICES "SPECIAL given at home, in a physician's PRACTITIONER" office or elsewhere. Covered SERVICES services include: including covered services • medical and surgical care provided by: • X-rays and other diagnostic • clinical psychologists and tests and procedures social workers • medical supplies, drugs you • registered nurse anesthetists can't take by yourself, and • physician assistants blood transfusions (a separate deductible may • nurse practitioners and clinical nurse specialists. apply for the first 3 pints) • physical and occupational therapy and other services. 8 OUTPATIENT HOME HEALTH SERVICES HOSPITAL SERVICES, which are also covered under including those given in an Medicare Hospital Insurance. If emergency department or you don't have Hospital Insurance, outpatient clinic. Medical Insurance provides coverage (if you meet certain conditions). AMBULANCE. SERVICES OTHER COVEREP SERVICES to a hospital or skilled nursing and supplies include: facility (or from the hospital or • ambulatory surgery (surgery skilled nursing facility to your not requiring an overnight stay) home). • rural health clinic services • outpatient physical and occupational therapy and speech pathology services • comprehensive outpatient rehabilitation facility services • Pap tests and mammograms • radiation therapy • kidney dialysis and transplants • certain drugs, vaccines and medical supplies. CERTAIN LIMITS ANP RESTRICTIONS MAY APPLY For more information, contact your local Social Security office or Medicare carrier (the organization that handles Medical Insurance claims). 9 costs YOUP- pepejjp OH "ASSIGNMENT" under Medical insurance. 'ACCEPTING "HOT ACCEPTING ASSIGNMENT" ASSIGNMENT" means your physician or other means your physician or other health- health-care provider agrees to care provider can charge a higher fee charge the Medicare-approved for the covered service. When this fee for a covered service. happens: When this happens: • Medicare pays 80% of the • Medicare pays 80% of the approved fee approved fee • you pay 20% of Medicare's • you pay only the remaining approved fee* - plus any difference 20%* - called "coinsurance. between the approved fee and the actual charge. NOTE: In 1992, the physician may not charge you more than 120% of the Medicare fee schedule for non- participating physicians. Assuming you've already paid the $100 annual deductible "MEDICARE-PAPTICIPATING" HEALTH-CAP-E PROVIDERS accept assignment on all Medicare claims. Those who don't participate in Medicare can choose to accept assignment or not. IO