Archive for the ‘Medicare’ Category

How Does Medicare Health Care Insurance Really Work

Thursday, February 3rd, 2011
by The Doctr

Medicare is the government’s contract to provide healthcare insurance coverage for Americans over the age of 65. But, as with all contracts, it’s always smart to read the fine print.

Medicare pays for about half of all medical costs for older Americans, including hospitalization, doctors, some nursing care, some prescription drug costs, and medical equipment and supplies. But there’s much that Medicare doesn’t cover, as well as an alphabet soup of coverages, premiums, deductibles, and eligibility requirements that can be difficult to navigate — especially for someone facing a health crisis.
Here are the basics everyone should know about Medicare, and where to look for more information if you need it:

What is Medicare?

Medicare consists of four categories: Part A covers hospitalization, some skilled nursing facility and home health care, and hospice. Part B covers doctors’ services and outpatient care such as X-rays, laboratory work, some home health care, physical and occupational therapy, and some preventive screening. Then there’s Part C, also known as Medicare Advantage, which is Medicare received through a private managed care system such as an HMO (health maintenance organization) or PPO (preferred provider organization). When someone enrolls in a Medicare Advantage plan, they receive all the benefits of Medicare Parts A and B, as well as some additional coverage provided by the private plan. As with other managed care, however, Medicare Advantage plans limit where and how their members may receive care. Finally, there’s Medicare Part D, which consists of private insurance plans that partially cover prescription drug costs.

Most people qualify for all Medicare programs if they’re 65 or older and are citizens or permanent residents of the United States. However, eligibility rules and availability are different for each plan within Medicare.

· For Part A, people are automatically eligible without paying any premium if, in addition to the age and residency requirements, they worked and paid Social Security taxes for at least ten years. If not, they may still buy into Part A coverage for a yearly premium.

· For Part B, every citizen and legal resident over 65 is eligible. Even if someone is under age 65, he or she may qualify for both Part A and B if he or she has been receiving Social Security disability benefits for two years or has a chronic kidney disease.

· If they’re eligible for Parts A and B, they can choose to receive that coverage through a Part C Medicare Advantage managed care plan, if a plan they like is available where they live.

· Anyone eligible for Medicare may purchase a Part D prescription drug plan offered by private insurance companies in the state where they live.
Enrollment is different for each part of Medicare. People who are receiving any type of Social Security benefits when they turn 65 will be automatically enrolled in Parts A and B. Medicare will send them enrollment cards and information about three months before their 65th birthdays. If they aren’t automatically enrolled, they may sign up for Part A or Part B at any local Social Security office. They should enroll two or three months before they turn 65, to ensure prompt coverage.
If they delay enrolling in Part A past their 65th birthday, their coverage can date back to up to six months before the date they do apply. Delaying enrollment in Part B is more of a problem. If they wait more than three months after their 65th birthday to enroll in Part B, they may not enroll until January 1 of the following year, and the coverage won’t start until July 1 of that year.

If they want to enroll in Part C or D of Medicare, they do so with the private managed care plan or insurance company that runs the particular plan or issues the policy they want. If they don’t enroll in Part C or D when they turn 65, or if they want to switch coverage under Part C or D, they can do so during Medicare’s annual enrollment period, which falls between November 15 and December 31. (Some managed care plans and insurance companies also allow enrollment throughout the year.)
They can go to any doctor, hospital, clinic, outpatient provider, nursing facility, home care agency, or pharmacy that is approved by Medicare and that accepts Medicare patients. Before a visit, it’s essential to verify that the doctor or other provider accepts Medicare.

What’s covered by Medicare?

Medicare is intended primarily to provide coverage if when someone becomes ill or injured. This includes hospitalization, doctors’ services, lab work, X-rays, hospice, and just about every kind of outpatient care, as well as some inpatient nursing facility and psychiatric care.
Over the years, however, Medicare has evolved to also cover a range of preventive and screening services through the Part B plan. Some of these services include cardiovascular screening; smoking cessation counseling; screening for breast, cervical, vaginal, colon, and prostate cancers; immunizations for flu, pneumococcal virus, and hepatitis B; diabetes screening and supplies; glaucoma tests; and a “Welcome to Medicare” physical exam. Most Medicare Part C managed care plans offer even more of these preventive and screening services.

For those who meet certain requirements for home health care, Medicare also pays for part-time nursing care; part-time health aides; speech, physical, and occupational therapy; and medical supplies and equipment such as bandages and wheelchairs.

Under Part D, the prescription drug benefit, Medicare covers part of the cost of approved generic and brand-name prescription drugs purchased at participating pharmacies.

Medicare isn’t intended or designed to provide long-term nursing home or in-home care, so there are significant gaps in these areas. Families can’t rely on Medicare to pay for 24-hour at-home care, meals, delivery services, and many of the personal services provided by home health aides (except for some skilled nursing care for a short time if it’s medically necessary ).

Although Medicare has added many preventive services to its coverage in recent years, many such routine care needs are not yet covered, including dental care, medical treatment outside the United States, routine foot care, glasses, and hearing aids. Medicare coverage for mental health treatment — including depression, which is a growing issue among people over 65 — is also significantly limited. And Medicare doesn’t cover elective procedures, including cosmetic surgery.

Most important, make sure the doctors you have in mind accept Medicare, or the program won’t pay for even covered costs. This is also true for outpatient care and home care, and for prescription drugs, which Medicare patients must buy from a pharmacy that participates in their particular Part D insurance plan.

Each part of Medicare has a different payment system. And within each part, patients’ out-of-pocket costs will depend on the particular way they receive their benefits. However, the following basic information about premiums and copayments holds true in most cases. The figures given are for 2010.

· Part A: Most people pay no premium for Medicare Part A. People who aren’t automatically eligible for Part A pay a monthly premium of up to 1. Everyone with Part A pays a deductible of ,100 for each period of hospitalization, and copayments for each day past the first 60 days of a particular hospital stay.

· Part B: Every individual pays a premium of at least .40 a month for Part B coverage, deducted from monthly Social Security checks; this figure goes up for people with high incomes. A person must also meet an annual deductible of 5. After the deductible, Medicare pays 80 percent of the approved amount for covered doctor services, and 80 to 100 percent of the approved amount for outpatient services and medical equipment. Those who don’t enroll in Part B when they turn 65 can enroll later — but each year they put it off, the premium increases by 10 percent.

· Part C: Part C Medicare Advantage private managed care health plans lump Part A and B together, offering one monthly premium and the plan’s own set of copayments and deductibles. It’s important to check not only premiums but also out-of-pocket costs when considering one of these plans.

· Part D: Every prescription drug plan under Part D has different premiums, copayments, and coverages. In choosing a plan, be sure not to focus solely on the lowest monthly premium but also on coverage of the specific drugs needed and any copayments that might apply.
Where can I find more information about Medicare?

More detailed information about each part of Medicare is offered in the articles on this site listed below. You can also look at the federal website for Medicare and Medicaid, as well as at Benefits Checkup, an online service run by the National Council on Aging that can help you identify which government benefits your seniors qualify for and how to enroll.

Find More Medicare Articles

Question by Dementia: When does Medicare require the referring doctor’s name on electronically filed claims?
I’ve run into problems when calling referring doctors’ offices for their NPI numbers, which are necessary if the referring doctor’s name is on the claim. Is the name of the referring doctor ALWAYS necessary on electronically-filed Medicare claims? Some offices don’t even know what one is!

Best answer:

Answer by Man of La Mancha

Know better? Leave your own answer in the comments!

What Is The Best Medicare Supplement Plan

Sunday, January 30th, 2011
by Korean Resource Center 민족학교

Best Medicare Supplement

Here’s an easy step-by-step guide to finding the best Medicare Supplement (also referred to as Medigap).

Most people want coverage for what they are paying out of their own pocket for Medicare’s co-insurance, co-pays and deductibles – and they want that coverage at the lowest possible price.

Here’s a secret that could save you a lot of time, money and effort – it’s one of the biggest differences in Medicare Supplement plans. Each insurer can sell the exact same Medicare Supplement plans at a different price!

Medicare Supplement plans are standardized so if you buy Plan F, for instance, from any insurer, you’ll get the same coverage, but you may find it at a much lower price with comparison-shopping.

You can get professional help to compare Medicare Supplement plans from the Medicare planning team at MediGap Advisors. With years of experience in Medicare Supplement insurance, these experts know Medicare Supplement plans and the insurers offering them.

Just call MediGap Advisors at 866-681-7712 to get the answers you need and find the best Medicare Supplement plans. MediGap Advisors can help you sort through the 10 Medicare Supplement plans now available by comparing your situation and needs to the benefits of each plan. They’ll take a look at your biggest health care expenses and show you the best Medicare Supplement plans to protect you from charges that Medicare doesn’t cover.

If hospital care is a big concern for you, you’ll need coverage for Medicare’s Part A ,100 deductible because you have to spend that much out-of-pocket per illness before Medicare pays for hospital bills. You can take care of the Part A deductible with any one of nine Medicare Supplement plans.

If you spend a lot on doctor office visits, you have to meet an annual Part B deductible before Medicare pays for your doctor bills. The best Medicare Supplement plans, the ones with the most comprehensive coverage, reimburse you for the Part B deductible.

Medicare Supplement plans C and F will reimburse you for that deductible regardless of how much it is in any given year.

Medicare pays for 80% of a pre-approved amount for doctors’ services, after the Part B deductible has been met. You can choose from seven of the best Medicare Supplement plans to pay for the 20% that’s left.

Your doctor may charge more for a procedure than Medicare will pay. When Medicare covers 80% of a pre-approved amount, Medigap covers 20% of the same pre-approved amount. Your doctor could charge a lot more than Medicare’s pre-approved amount and leave you to make up the difference.

The best Medicare Supplement plans help with doctor’s excess charges. Medigap Plan G pays for 80% of any doctor charges above what Medicare will pay. For a slightly higher premium, Plan F will cover 100% of these excess charges.

The best Medicare Supplement plans help whenever Medicare doesn’t completely cover your health care expenses. That includes doctor and hospital bills, but it also helps with skilled nursing facilities and even emergency care when you’re traveling out of the country.

If you have to go to a skilled nursing facility, Medicare will cover 20 days of care in a skilled nursing facility following hospitalization. You have to meet your Part A deductible before Medicare picks up the charges. After 20 days, you have to pay for a portion the daily costs from day 21 through 100, but eight Medigap plans will pay your share for those days.

If you travel abroad, Medicare has no coverage at all for any emergency medical care outside of the country. You can travel safely with several of the best Medicare Supplement plans. They will cover 80% of your emergency medical care during the first 60 days you’re abroad, with a 0 deductible.

The best Medicare Supplement plans cover your costs whenever Medicare will not pay.

To find the plan that’s just right for you, list your biggest health care costs and see which Medicare Supplement plans cover those charges for the lowest premiums. After you compare Medicare Supplement plans, compare the prices different insurers are offering on the plan you like most.

You can save a lot of time and effort with free professional advice from the Medicare Supplement experts.

As the nation’s leading independent agency specializing in Medicare Supplement plans (Medigap plans), MediGap Advisors can show you how you can save money with the best Medigap plans that fit your needs and your situation.

Related Medicare Articles

Question by glory: Medicare question: Should I choose a Medicare Advantage Plan or go with Medicare and a Supplement?
I’m turning 65 soon. So I’m faced with a choice: Do I choose to go with Medicare and a medicare supplement plan? Or do I choose a Medicare Supplement Plan such as the AARP United Health plan? Can anyone recommend a supplement with a low monthly premium? Seniors, what is your experience? Any tips you’d like to share?

Best answer:

Answer by mamacedar
I signed up with the one that walmart sells – Secure Horizons by United Healthcare. There are no premiums to pay. I don’t understand how it works, but somehow Medicare pays for it. My only copay is office visit $ 5, Spec/$ 15 and ER $ 50. The phone number on the back of the card is 1-866-579-8774 .

I already had some other health plan which deducted money from my SS check, but there was this ‘sales lady ‘ standing in a booth at Walmart and when I told her how great mine was she said I can give you a policy that has no payment removed from your ss check. She came over to our house showed us all the details, answered all our questions, and we signed up for it. Sounds too good to be true, but so far it has paid everything (including RX) that we have needed.

What do you think? Answer below!

Can Someone File a Medicare Lien Against Me?

Sunday, December 19th, 2010
by Korean Resource Center 민족학교

Resolving the Medicare lien is the claimant’s problem.

Resolving Medicare’s right to reimbursement of payments for medical treatment related to an injury upon which a negligence, workers’ comp, malpractice, no fault or other civil law claim has been made is the obligation of every party to the injury claim.

The Medicare Secondary Payer (MSP) statute -42 USC 1395y(b)(2)-, regulations under that statute -42 CFR 411.21 et seq.- and the Medicare, Medicaid and SCHIP Extension Act of 2007 -42 USC 1395y(8)- create obligations on the part of the Medicare beneficiary, the beneficiary’s attorney, the party against whom a civil claim is made by a Medicare beneficiary and the insurers of both the beneficiary and the claim respondent. Those obligations include reporting the claim to the Centers for Medicare and Medicaid Services (CMS), reimbursing past payments made by Medicare related to the claim and protecting Medicare’s interests related to future payments related to the claim.

The personal injury claim respondent and its insurer need not worry about the Medicare lien if there is no finding or admission of liability for the injury that was treated by Medicare.

The MSP statute makes clear that the party / insurer claimed to be responsible to cover treatment that in fact has been provided by Medicare becomes primary to Medicare and thus owes reimbursement by making any payment in settlement of the claim, even if liability for the injury/treatment is never established and in fact is denied. 42 USC 1395y(b)(2)(B)(ii).

No one needs to worry about a Medicare lien unless Medicare takes some affirmation action to notify parties of the lien and requests reimbursement.

Medicare is not required to notify anyone of its right to reimbursement and is not required to make a request for reimbursement in order to enforce its right to recovery.  Federal law obligates the parties to the injury claim to notify Medicare of the claim and to take specific action to determine the amount of the reimbursement amount and to make reimbursement within a specified period of time.

Medicare is only entitled to recover reimbursement from that portion of the settlement allocated to medical expenses.

Medicare’s right to reimbursement is not dependent on whether or to what extent there is any allocation of the settlement to various types of loss. However, Medicare does recognize allocations of settlements to nonmedical losses when payment is based on a court order on the merits of the case and will not seek recovery from portions of court awards designated as payment for nonmedical losses. Medicare Secondary Payer Manual, section 50.4.4.

Initiating contact with Medicare regarding resolution of its right to reimbursement should not be done until the claim is settled.

Resolving a Medicare lien is a multi-step process that can take months to complete and should be started well before settlement is reached.  Those steps include reporting the claim to Medicare’s Coordination of Benefits Contractor, communicating with the Medicare Secondary Payer Recovery Contractor to determine what Medicare payments were and were not related to the underlying claim and, when required, asking that the Medicare lien amount be compromised or waived in order to allow the claim to settle. In many cases it makes more sense to handle lien waiver and compromise negotiations before settlement is reached.

There is no process for review or appeal from a determination on a Medicare lien determination.

There is an established, multi-level review and appeal process from the determination of the amount Medicare is entitled to recover.

The new mandatory insurer reporting law requires the use of Medicare set-asides in settlement of non-workers’ compensation cases.

The Medicare, Medicaid and SCHIP Extension Act of 2007 imposes new requirements for reporting of negligence, no fault, malpractice, uninsured motorist and other non-workers’ compensation claims of Medicare beneficiaries.  The law does not expand the requirement for the creation of Medicare set-aside accounts beyond the current requirement for use of set-asides in settlement of certain workers’ compensation cases.

Implementation of the new reporting requirements has led to greater awareness of the already existing obligation of the parties to personal injury claims of all kinds to protect Medicare’s interests in settlement of those claims. Even in non-workers’ compensation settlements, Medicare set-asides may be used to demonstrate that the parties took Medicare’s interests into consideration in the settlement. However, there are other ways to protect Medicare’s interests in non-workers’ compensation settlement short of creating a set-aside account.

Where the Medicare lien exceeds the amount of the settlement (or exceeds the amount of the policy limits) the entire settlement amount will be taken by Medicare.

Medicare’s final reimbursement demand will reflect reductions in consideration of attorney fees and costs incurred in prosecuting the personal injury claim under 42 CFR 411.37 and Medicare has a process for waiving its reimbursement or compromising the amount of its recovery depending on the individual facts and circumstances of the case. 42 CFR 411.28; 42 CFR 401.613

Attorneys representing parties to personal injury claims don’t have to worry about penalties or sanctions directed at them if their clients don’t comply with Medicare reimbursement and reporting requirements.

CFR 411.24(g) makes an attorney who receives funds from a primary payer liable to reimburse Medicare conditional payments.  The federal courts have recognized the attorney’s obligations and liability for payment to Medicare when reimbursement requirements are not met. U.S. v. Paul J. Harris, 2009 WL 891931 (N.D.W.Va.)

In most states rules are in effect governing attorney conduct modeled on ABA Model Rule 1.15(d), requiring attorneys to notify third parties (such as Medicare) when client funds in which the third party may have an interest come into the attorney’s hands and to deliver client funds to the third party once the third party’s interests are established.

Attorneys have an established obligation to Medicare and May 2009 amendments to the federal False Claims Act create the opportunity for expanded sanctions against attorneys for failing to comply with an obligation owed to an agency of the federal government.

Medicare reimbursement requests only include payments made by Medicare that were for treatment related to the injury involved in the underlying personal injury claim.

Although Medicare is only entitled to reimbursement of payment made for treatment of the injury involved in the personal injury claim the reality is that many Medicare requests for reimbursement include payments made by Medicare to treat medical conditions that pre-existed the claim injury or were otherwise unrelated to the claim injury.  It is important to audit the reimbursement requests to identify and then challenge the request for reimbursement of payments for unrelated treatment.

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Question by Suzi P: Medicare…?
my parents are with medicare, and like… they say that they don’t cover braces, but the girls at my school say that they do.

i think my parents are lying to me.

i already have orthodontic plates, but i’ve had them for 4 years and worn them every day, but they haven’t done much.

i really NEED braces….

really really

does anyone know
a) how i can convince them to let me
b) does medicare cover the cost, if so how much of the cost?

thank you all !!

Best answer:

Answer by diggitystud m
Your parents are right. Medicare is a government program that entitles people 65 and older to certain health care like hospital bills, drugs, and so on.

So unless you are 65 or older you are not elligable for medicare.

You and your friends could be confusing medicare with medical insurance which is a totally different matter.

Give your answer to this question below!

What Are The Recent Changes in Healthcare and Medicare?

Friday, December 17th, 2010
by Korean Resource Center 민족학교

Despite recent economic strain, US citizens on the cusp of senior status are still springing into action when it comes to purchasing Medicare supplement plans in anticipation of upcoming healthcare needs. With inflation rates and projected healthcare costs continually escalating, it seems as though many emerging senior citizens may need to take extra precautions, in terms of both personal savings and Medicare supplement selection.

A recent study performed by the Employee Benefits Research Institute (EBRI) describes the degree of savings needed to obtain a quality medicare supplement plan:

“…a man retiring this year at age 65 will likely need between ,000 to 8,000 in savings to cover insurance premiums and out-of-pocket expenses during retirement. The differences in dollar amounts are based on the statistical chances of an individual having enough money. In other words, it one wants to be 90% sure of having enough in savings, he would need the higher amount; for a 50% chance he would need at least the lower amount.”

The EBRI study also described the divergence between supplement plans for men and women.

“Because women live longer, they need even more money. A women retiring at age 65 in 2009 will need from ,000 to 2,000 in savings to cover insurance premiums and out-of-pocket expenses in retirement for a 50/50 chance of having enough money, and 4,000 to 0,000 for a 90% chance, said the report’s author, Paul Fronstin, an EBRI researcher.”

Due to these striking figures and countless others, many soon-to-be retirees are reconsidering their options. Instead of shifting directly into a life of leisure, many current 50-somethings are beginning to save their money more scrupulously. This shift in priorities has been understandably upsetting to many, but imperative nonetheless.

The current state of Medicare and the overall healthcare system has made selecting the right Medicare supplement plan more important than ever, and by working with the experts at, you can rest assured that you have gotten the best possible value for your healthcare dollar.

Find More Medicare Articles

Question by Melissa: medicare???
on my pay stub, it says “medicare employee” as a tax. does that mean i have health insurance or is that something they just take out of everyones paycheck??

Best answer:

Answer by Asystole
Its the medicare tax – it’s taken out of everyones check

Add your own answer in the comments!

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