• In addition, Medicare health plans may cover extra benefits not covered by Original Fee-for-Service Medicare, such as:
  • Lower Cost Sharing [Note: a few plans also reduce the Part B premium.]
  • A Maximum Limit on Out-of-Pocket Costs
  • Vision Services
  • Hearing Services
  • Dental Services
  • Podiatrist Services
  • Complementary Care, which may include Chiropractic Services, Massage Therapy, Naturopath, Acupuncture, given plan service area

PART A

• Most individuals automatically get Part A coverage without having to pay a monthly payment. This is because they or a spouse paid Medicare taxes while working.
• These individuals receive Part A coverage without paying a Part A premium.
• For those individuals who do not automatically qualify for Part A coverage, the Part A premium is $443 a month in 2009*.
• Individuals with disabilities who are under age 65 are automatically enrolled in Part A after they have received Social Security or Railroad Retirement disability benefits for 24 months.

• Part A helps cover inpatient care in hospitals that is medically necessary. In 2009, for each benefit period (as defined by Medicare) in a year, beneficiaries pay:
  • $1,068 deductible and no coinsurance for a for a stay of up to 60 days*
  • $267 per day for days 61-90 of a hospital stay*
  • $534 per "lifetime reserve day" after day 90 each benefit period (up to 60 days over your lifetime)
  • All costs for each day over 150 days (after $512 per day for 60 lifetime days) *
  *This is/these are the amounts for 2009 and may change January 1, 2010.
  
  
• Part A also helps cover:
  • Blood
  • Hospice care
  • Home health care
  • Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period (as defined by Medicare), but not custodial or long-term care
  • Inpatient psychiatric care (up to 190 lifetime days) in a psychiatric hospital
• Cost-sharing and the number of covered days may differ for enrollees of Medicare health plans.

PART B

• At Age 65
• Most individuals who file an application for Social Security or Railroad Retirement benefits 3 months before they turn age 65 or later are automatically enrolled in Part B unless they refuse Part B coverage.

Disability Under Age 65

• Individuals with disabilities receiving Social Security or Railroad Retirement benefits at least 4 months before they turn age 65 are automatically enrolled in Part B the month they turn age 65, but are given the opportunity to refuse Part B coverage.
• Individuals who are under age 65 and have a disability are enrolled in Part B after they have received Social Security disability or Railroad Retirement benefits for 24 months. [Note: Exception for ALS, i.e., Lou Gehrig’s disease.]

• Beneficiaries enrolled in Part B must pay a monthly premium. Most beneficiaries pay the standard monthly premium for Part B - $96.40 in 2009. Individuals with income over $85,000, or filing jointly with incomes over $170,000, pay more, up to $308.30 a month in 2009.*
• Part B premiums are deducted from Social Security checks, Railroad Retirement checks, or Office of Personnel Management benefits.
• Individuals who do not enroll in Part B when first eligible (e.g., at age 65) can enroll during a General Enrollment Period in January - March.
• Part B coverage begins on July 1 of the year they enroll.
• The Part B premium is increased 10% for each full 12-month period the beneficiary could have had Part B but didn't enroll.
• Exception: Individuals who have group health plan coverage based on their own current employment or the employment of a spouse may enroll in Part B during a special enrollment period and are not subject to the premium increase.

• Generally covers physician and other health care professional services, outpatient hospital, clinical lab and diagnostic tests, therapies, mental health care, medical equipment, and medications and supplies provided incident to a physician service.
• Beneficiaries pay a deductible each year ($135 in 2008), and after the deductible is satisfied, 20% coinsurance on most Part B covered services.*
• Cost-sharing may differ for enrollees of Medicare health plans.

• Ambulance services
• Limited chiropractic services
• Costs of certain care for beneficiaries in approved clinical trials
• Diabetic supplies
• Durable medical equipment
• Emergency room services
• Eyeglasses after cataract surgery
• Foot exams if a beneficiary has diabetes-related nerve damage
• Kidney dialysis, services and supplies
• Medical nutrition therapy services for people who have diabetes or kidney disease
• Certain outpatient mental health services
• Prosthetic/Orthotic items
• Second surgical opinions
• Telemedicine services in some rural areas
• Tests like X-rays, MRIs, CT scans, EKGs
• Transplant services

• One-time "Welcome to Medicare" physical exam (within 6 months of your 65th birthday)
• Immunizations-pneumococcal, hepatitis B, annual flu shot
• Bone mass measurements-every 24 months for certain conditions
• Cardiovascular screening blood tests-every five years for all persons
• Colorectal cancer screening-four different tests vary in frequency
• Diabetes screenings-up to two per year for anyone with risk factors
• Diabetes self-management training-for persons with diabetes
• Glaucoma testing-once per year for those at high risk
• Mammogram-annual screening for all women
• Pap test and pelvic examination-every 24 months for all women and every 12 months for those at high risk
• Prostate cancer screening-every 12 months for all men
• Smoking cessation counseling - for any smoking related illness

• Acupuncture
• Dental care/dentures
• Cosmetic surgery
• Custodial care
• Health care while traveling outside the US
• Hearing aids/exams
• Orthopedic shoes
• Outpatient prescription drugs (this is covered under Part D)
• Routine foot care
• Routine eye care and eyeglasses
• Routine physical exams, except the one-time Welcome to Medicare physical
• Some screening tests and labs
• Vaccines, except as previously listed (those not covered under Part B are covered under Part D)
• Syringes and insulin unless used with an insulin pump (this is covered under Part D)

PART C

• Part C Medicare Advantage Health Plan
• Individuals who are entitled to benefits under Part A and enrolled under Part B are eligible to enroll in a Medicare Advantage plan.

PART D

• Individuals who are entitled to benefits under Part A and/or enrolled under Part B are eligible for Part D prescription drug benefits.
• Enrollees may be enrolled in a stand-alone PDP only if they are enrolled in:
  • Original fee-for-service Medicare;
  • Private Fee-for-service (PFFS) without Part D drug coverage;
  • Medical Savings Account (MSA); or
  • 1876 Cost Plan
• For 2010, the standard benefits requires the benenficiary to pay:
  • $310 deductible (annual)
  • 25% of costs between $310 and $2,830 = $630
  • 100% of the next $3,610 in drug costs (the "coverage gap"), then
  • After the beneficiary has paid $4,550 out-of-pocket, catastrophic coverage begins.
    • On any future prescriptions the beneficiary pays either a co-pay of $2.50 for generic drugs or $6.30 for brand name drugs or a co-insurance of 5%, whichever is greater.

• A beneficiary in Original Medicare may receive Part D prescription drug coverage through a stand-alone prescription drug plan (PDP).
• A beneficiary may also leave Original Medicare and receive drug coverage through a Medicare Advantage health plan (MA-PD) or sometimes through a Medicare Advantage (MA) plan and a separate PDP.
• With the exception of those dually eligible for Medicare and Medicaid, Medicare beneficiaries must actively select a Part D plan.
• Beneficiaries who enroll typically pay a monthly premium, annual deductible and per-prescription cost-sharing. There is a gap in coverage where enrollees pay all expenses and a catastrophic level at which the plan covers 95% of costs. Extra help is available for low-income beneficiaries.
• There is a permanent premium penalty of 1% of the national standard premium for every month that a beneficiary could have had Part D coverage and chose not to enroll.
• Open enrollment is from November 15 to December 31 each year.

STATE ASSISTANCE PROGRAMS

• Beneficiaries with limited income and resources should be encouraged to apply to their State Medicaid office to determine eligibility for various programs.
• Beneficiaries may qualify for help from the State to pay the Medicare Part B premium, the Part A and Part B deductibles and cost sharing, and/or some Part D prescription drug costs
• Advise them to call 1-800-Medicare (1-800-633-4227) and just say Medicaid for the State Medicaid telephone number.
• Beneficiaries may qualify for help through these programs:
  • Medicaid: help with health care costs. Apply to State Medicaid office.
  • Medicare Savings Program: help paying Medicare Part B premiums and, in some cases, deductibles and coinsurance. Apply to State Medicaid office.
  • Part D low-income subsidy: help paying for prescription drug coverage. Apply to State Medicaid office and State will check for eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D help only may call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov/prescriptionhelp.
  • Supplemental Security Income (SSI) benefits: help with cash for basic needs. Apply to state Medicaid office.

FOR MORE INFORMATION ABOUT MEDICARE

• Centers for Medicare & Medicaid Services www.cms.hhs.gov/ (technical information)
• www.medicare.gov/ (beneficiary audience)
• Medicare & You Handbook
• Your Medicare Benefits

Note: Original Fee-for-Service (FFS) Medicare is also referred to as Original Medicare or the Original Medicare Plan

To learn more,  Contact us.

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