MEDICARE 

Overview
Medicare is a federal health insurance program administered by the Social Security Administration. Medicare will only pay for "medically reasonable and necessary" services or supplies from a Medicare-certified provider. 

In some parts of the country, you can get your health care coverage through the Medicare + Choice program as well as the original Medicare plan. However, beneficiaries do not have to choose to move out of the original Medicare program. 

Who is eligible for Medicare? 
Unlike Medicaid, your income and assets are not considered in determining eligibility. The following groups of people are eligible for Medicare: 

• Persons age 65 and eligible to receive Social Security, Widow's Benefits or Railroad Retirement Benefits. 

• Disabled persons under age 65 who have received Social Security or Railroad Retirement Benefits for 24 months. You do not have to wait 24 months if you are a kidney dialysis or kidney transplant patient. 

• Persons age 65 or older and not eligible for Social Security or Railroad Retirement may enroll and receive Medicare by payment of a monthly premium for Part A coverage. 

Medicare Premiums 
Medicare Part A coverage includes inpatient hospital care, hospice care, inpatient care in a skilled nursing facility, and is no cost to Medicare recipients that are eligible for Social Security or Railroad Retirement. 

Persons that are age 65, not eligible for Social Security or Railroad retirement, may voluntarily enroll and pay a premium for Part A coverage: 

$300 per month if less than 29 quarters of Social Security coverage. 

$165 per month if 30-39 quarters of Social Security coverage. 

Medicare Part B coverage includes medical care and services provided by doctors, home health care and durable medical equipment. Beneficiaries must pay $50 per month for this coverage, which is deducted from the social security check. There is a late enrollment penalty added to the beneficiary's Part B premium if the beneficiary does not enroll in the program at age 65. 

Hospital Care 
Medicare pays hospitals a fixed amount based upon the patient's diagnosis (this is called the prospective payment system). There is an incentive for hospitals to discharge patients as soon as possible so that it does not cost more to treat the patient than 
Medicare will pay. 

Benefit Periods 
Up to 90 days of hospital services are covered per benefit period. The benefit period begins when the patient enter the hospital and ends when the patient is out of the hospital 60 consecutive days. 

Deductible and Co-payments 

$792 first day deductible per benefit period 

$198 per day co-payment for day 61 through 90 

$396 per day for days 91-150 (reserve days) 

Discharge Planning 
Hospitals that participate in the Medicare program, must meet the Medicare discharge planning requirements. The hospital must have written discharge planning policies and procedures. 
Hospitals must provide a discharge planning evaluation when requested by the patient, someone on the patient's behalf, or a physician. 

The evaluation must include: 

• an evaluation of the likelihood of the patient needing post -hospital services, 

• the availability of such services and 

• the possibility of the patient being cared for in the environment from which he entered the hospital 

Physicians' Bills 
Physicians who participate in the Medicare Physician Assignment Program agree to accept the Medicare reasonable charge amount as payment in full. Medicare pays the doctor 80% of the reasonable charge amount and the patient pays the remaining 20%. 

If the doctor does not participate in the Program, the patient may have to pay the remaining 20% plus whatever the doctor charges above the Medicare reasonable charge amount. However, there is a limit on what the doctor may charge. This is called the Medicare limiting charge and it sets a cap on what nonparticipating doctors may charge Medicare patients. 

There is a $100 per year deductible. 

Nursing Home Care 
Medicare only pays for skilled nursing home care. Most nursing home care is intermediate care, not skilled care. 

The patient must have been hospitalized for at least 3 days before admission to the nursing home Medicare will cover up to 100 days of skilled care only, and there is a co-payment of $99 per day for days 21 through 100. 

Home Health Care 
There is no deductible or co-payment for home health services except a 20% co-payment for durable medical equipment. 

Medicare will pay for home health care if all of the following conditions are met:

• A doctor certifies the need for the services and establishes a plan of care. 

• The patient is confined to his home. However, there can be absences for medical purposes or for infrequent or short non-medical purposes. 

• Patient needs part-time or intermittent skilled nursing care, or physical, occupational, or speech therapy. 

Medicare will not pay for custodial care. The patient must require the services of a registered nurse, physical therapist, speech language pathologist, or occupational therapist. In most cases, the patient must require a skilled nursing service at least once every 60 days. The patient may be in need of skilled care even where there is a chronic or terminal illness or care is needed over a long term. Management and evaluation of a patient care plan involving unskilled services can qualify as skilled care. 

The care is provided by, or under arrangement with, a Medicare-certified home health agency. The agency assesses the patient, draws up a plan of care for no more than 60 days and obtains certification of the plan from the doctor. 

If the conditions are met, Medicare should pay for the following types of services: 

• Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;

• part-time or intermittent services of home health aides; 

• physical, occupational, and speech therapy;

• medical social services provided under the direction of a physician; 

• medical supplies and the use of medical appliances; 

Obtaining Medicare Home Health Coverage 
The home health agencies are crucial to getting Medicare to pay for home health services. The agencies are reluctant to provide care in many cases because the Medicare rules are difficult for the agencies to interpret and they do not want to provide care if they are not going to be paid. In addition, Medicare regulations punish those agencies that 
submit claims that are rejected.

It is important that the patient's doctor establish a comprehensive plan of care that indicates the type of care needed by the patient, what professional should provide the care, and the nature and frequency of the services needed by the patient. Find the agency that will provide the most care and try to keep them providing care after the first 60 days if the patient still needs care.

Hospice Care 
Patient's doctor must certify that the patient is terminally ill. This requirement will be met if the patient's life expectancy is six months or less.

Services are for the palliation and management of the terminal illness and are part of a written plan of care established by the attending physician, a hospice physician and the hospice interdisciplinary group. 

Some of the types of services covered: 

• Physician and nursing care; 

• Counseling services provided to the terminally ill patient and the family members or other persons caring for the individual at home; 

• Home health aide services; 

• Homemaker services; 

• Physical therapy, occupational therapy and speech-language therapy provided for purposes of symptom control or to enable the patient to maintain activities of daily living. 

Medical Services Not Covered by the "Original" Medicare Program: 

• Prescription drugs 

• Routine physical 

• Eyeglasses or contact lenses 

• Hearing aides 

• Dental care 

Medicare Supplemental Insurance

Medicaid 
If a Medicare beneficiary qualifies for Medicaid, her Medicare premium, co-payments and deductibles will be covered and most of the services not covered by Medicare, such as prescriptions, will be covered by Medicaid. Therefore, she will not need to purchase any additional insurance. 

Qualified Medicare Beneficiaries (QMB) 
Limited Medicaid coverage is available to a Medicare recipient with income less than $736 per month ($988 per month for a couple). These 

amounts increase every year.

The Medicare beneficiary must own less than $4,000 in countable assets ($6,000 for a couple). 

Medicaid will pay the Medicare premiums, deductibles, and co-payments for QMB's. 

None of the services that are not covered by Medicare, such as prescriptions, will be covered. 

Special Low-Income Medicare Beneficiaries (SLMB) 
Medicaid will only pay the Medicare Part B premium for a Medicare recipient with income less than $855 per month ($1,145 for a couple). These amounts will increase in the Spring of 2001. Asset limits are the same as with QMB coverage. 

Qualifying Individual (QI-1) 
Medicaid will pay the Medicare Part B premium for a Medicare recipient with income less than $960 per month ($1,286 for a couple) but only if the limited funds budgeted for this are still available. 

Qualifying Individual (QI-2) 
Medicaid will only pay a small part of the Medicare part B premium if your income is less than $1,238 per month ($1,661 for a couple). These amounts will increase in the spring of 2001 

Medigap Insurance 
A person in the "original" Medicare program, who does not qualify for Medicaid, will have many gaps in her coverage. Therefore, she may need to purchase a private medigap policy to cover those costs that Medicare will not pay. 

The policies that plug the most gaps in Medicare coverage are, of course, the most expensive. Consumers can buy cheaper policies that don't plug all the gaps.

Federal law provides for certain rights for purchasers of these policies. 

Appeals 
A beneficiary is entitled to a speedy appeal process if she is in the hospital and told that Medicare will no longer cover her care or if she is denied admission to a hospital because Medicare will not pay. 

Any other decision to deny coverage of a Medicare service can be appealed and notices the beneficiary receives should explain the process. 

If you feel that Medicare should have paid for your medical care and your doctor agrees, you may want to pursue an appeal because many persons are able to receive additional Medicare coverage through an appeal. 


Resources 

Center for Medicare Advocacy, Inc. 
Health Care Financing Administration
(202) 216-0028 
www.hcfa.gov
www.medicareadvocacy.org 

Social Security Administration
National Senior Citizens Law Center 
1101 14th St., NW Suite 400 
Washington, DC 20005 
(202) 289-6976
www.ssa.gov

National Senior Citizens Law Center
www.nsclc.org 

Centers for Medicare & Medicaid Services (CMS) 
& U.S. Department of Health & Human Services: Medicare - 
The Official U.S. Government Site for People with Medicare.
www.medicare.gov 

This information has been provided by Jay W. Speer, Attorney at Law, Virginia Poverty Law Center. 5/1/01

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