File 05-10043.TXT Uploaded from F.L.I.C.net on 16-NOV-93 1-(607)-272-1549 (7 days-24 hours, 8-N-1) F.L.I.C.net operated by the: Finger Lakes Independence Center 607 W. Clinton Street Suite 112 Ithaca NY, 14850 Voice/TTY 1-(607) 272-2433 SYSOP: Jon W. Merritt Virus Scanned, McAfee Associates 9.12 V100 U.S. Department of Health and Human Services Social Security Administration SSA Publication No. 05-10043 January 1992 ICN 460000 Booklet title: "Medicare" -------------------------------------------------------------------------- Page 1 WHY YOU SHOULD READ THIS BOOKLET Because, sooner or later, nearly every American will be affected by Medicare, the Nation's only Federal health insurance program. In fact, if you pay taxes, you're already affected by Medicare because a portion of your taxes are used specifically to finance part of the Medicare program. But even though you're paying for the program now, and will likely come to rely on it in the future, chances are you don't know what Medicare offers--and what it doesn't offer. So take a few moments to go over the basics given in this booklet. The time you spend reading this booklet is an important investment in your future. Please Note: This booklet refers to premium amounts, "deductibles," "coinsurance payments," and other figures that change every year. For the most up-to-date information about these numbers, ask Social Security for a copy of the fact sheet, Social Security Update (Publication No. 05-10003). -------------------------------------------------------------------------- Page 2 WHAT'S INSIDE Page 3 Section 1--What Is Medicare? Page 4 Section 2--Who Can Get Medicare? Page 8 Section 3--How Do You Sign Up For Medicare? Page 14 Section 4--What Does Medicare Cover? Page 20 Section 5--What Medicare Does Not Cover Page 21 Section 6--Your Right To Make Health Care Decisions Page 22 Section 7--What If You Think You Need More Insurance? Page 25 Section What You Should Know If You Have Other Health Insurance Page 29 Section 9--Want More Information? Page 30 Other Booklets Available 31 Index Page 31 Index -------------------------------------------------------------------------- Page 3 SECTION 1 WHAT IS MEDICARE? Medicare is our country's health insurance program for people 65 or older, certain disabled people under 65, and people of any age who have permanent kidney failure. It provides basic protection against the cost of health care, but it doesn't cover all your medical expenses. The Health Care Financing Administration is the Agency that is in charge of running the Medicare program. But we--the Social Security Administration--are the people who will help you enroll in the program, and give you general Medicare information like that found in this booklet. MEDICARE HAS TWO PARTS There are two parts of Medicare. They are: HOSPITAL INSURANCE (also called "Part A" Medicare), which is financed by part of the payroll (FICA) tax that also pays for Social Security; and MEDICAL INSURANCE (also called "Part B" Medicare), which is financed by monthly premiums paid by people who choose to enroll. The two parts of Medicare cover different kinds of medical costs, have different rules about enrolling, and so on. Because of these differences, the two parts of the Medicare program are described separately in many sections of this booklet. -------------------------------------------------------------------------- Page 4 A WORD ABOUT MEDICAID Many people think that Medicaid and Medicare are two different names for the same program. But actually, Medicaid is a State-run program designed primarily to help those with low income and little or no resources. While the Federal government helps pay for Medicaid, each State has its own rules about who is eligible and what is covered under Medicaid. Some people can qualify for both Medicare and Medicaid. If you would like to know more about the Medicaid program, contact your local social services or welfare office. SECTION 2 WHO CAN GET MEDICARE? HOSPITAL INSURANCE IF YOU ARE 65 OR OLDER Most people 65 or older are eligible for Medicare hospital insurance based on their own--or their spouse's employment. You are eligible at 65 if: * You are getting Social Security or railroad retirement benefits, or * You are not getting Social Security or railroad retirement benefits, but you have worked long enough to be eligible for them, or * You would be entitled to Social Security benefits based on your spouse's work record, and your spouse is at least 62 (your spouse does not have to apply for benefits in order for you to be eligible based on your spouse's work) or, * You have worked long enough for Federal State, or local government to be insured for Medicare. -------------------------------------------------------------------------- Page 5 IF YOU ARE UNDER 65 Before age 65, you are eligible for Medicare hospital insurance if: * You have been getting Social Security disability benefits for 24 months, or * You have worked long enough in Federal State, or local government, and you meet the requirements of the Social Security disability program. If you receive a disability annuity from the Railroad Retirement Board, you will be eligible for hospital insurance after you serve a waiting period. (Contact your railroad retirement office for further details.) FAMILY MEMBERS WHO CAN GET MEDICARE Under certain conditions, your spouse, divorced spouse, widow or widower, or a dependent parent may be eligible for hospital insurance when he or she turns 65, based on your work record. Also, disabled widows and widowers under 65, disabled divorced widows or widowers under 65, and disabled children may be eligible for Medicare. IF YOU HAVE KIDNEY FAILURE There are special rules for people with permanent kidney failure. Under these rules, you are eligible for hospital insurance at any age, if you receive maintenance dialysis or a kidney transplant, and: * you are insured or are getting monthly benefits under Social Security or the railroad retirement system, or * you have worked long enough in government to be insured for Medicare. -------------------------------------------------------------------------- Page 6 In addition, your spouse or child may be eligible, based on your work record, if she or he receives maintenance dialysis or a kidney transplant, even if no one else in the family is getting Medicare. IF YOU DO NOT QUALIFY UNDER THESE RULES Certain aged or disabled people who do not qualify for Medicare hospital insurance under these rules may be able to get it by paying a monthly premium. See page 10 for information about buying hospital insurance. MEDICARE MEDICAL INSURANCE Almost anyone who is 65 or older--or who is under 65 but eligible for hospital insurance can enroll in Medicare medical insurance by paying a monthly premium (more on this in the next chapter). You don't need any Social Security or government work credits to get this part of Medicare. Aliens 65 or older who are not eligible for hospital insurance must be lawfully-admitted permanent residents and must live in the U.S. for 5 years before they can enroll in medical insurance. QUESTIONS? We realize that these rules can be confusing. If you aren't sure if you qualify for Medicare, or you need more information about the rules given here, contact Social Security. (But, if you get a railroad retirement annuity or railroad retirement benefit based on disability, you should contact a railroad retirement office.) -------------------------------------------------------------------------- Page 7 HELP FOR LOW-INCOME MEDICARE BENEFICIARIES--THE QMB PROGRAM If you get Medicare, and you have little income or assets, you should know about a program that can help save you money. It is called the "Qualified Medicare Beneficiary" or "QMB" program. The QMB program is run by the Health Care Financing Administration and the State agency that provides medical assistance under the Medicaid program. If you qualify for help from the QMB program, your State will pay your monthly Medicare premiums. Your State will also pay the Medicare deductibles and coinsurance, which can save you a lot more money. The rules vary from State to State. But, in general, you may qualify for help from the QMB program if: * your income is limited; and * your "resources" do not exceed certain limitations. (Resources are things you own. But some things don't count. For example, the home you live in doesn't count, and some other things such as a car may not count either.) Only your State can decide if you qualify for help under the QMB program. If you think you may qualify, contact your State or local medical assistance (Medicaid) agency, social service office, or welfare office. For general information, ask Social Security for a copy of the fact sheet , You Should Know About QMB (Publication No. 0510079). -------------------------------------------------------------------------- Page 8 SECTION 3--HOW DO YOU SIGN UP FOR MEDICARE? In Section 2 of this booklet, we talked about who is eligible for Medicare. The next logical question is, "How do I get Medicare when I'm eligible for it?" The answer to this question depends on a number of factors. And once again, the rules are different for the two different parts of Medicare. Let's start with the rules for hospital insurance. GETTING MEDICARE HOSPITAL INSURANCE (PART A) Some people have to apply for hospital insurance. For others, it starts automatically. IF YOU ARE ALREADY GETTING SOCIAL SECURITY OR RAILROAD RETIREMENT CHECKS If you are already getting checks when you turn 65, you will be automatically enrolled in hospital insurance. You will get a package in the mail 2 or 3 months before you turn 65. The package will have your Medicare card in it, along with more information about the Medicare program. (The package will also ask you to decide if you want to pay a monthly premium to sign up for the medical insurance part of Medicare.) IF YOU PLAN TO RETIRE AT 65 If you plan to retire when you turn 65, contact Social Security about 3 months before your 65th birthday. We'll sign you up for Medicare at the same time you apply for Social Security benefits. -------------------------------------------------------------------------- Page 9 IF YOU'RE ABOUT TO TURN 65, BUT YOU DON'T PLAN TO RETIRE You don't have to retire to get Medicare hospital insurance at 65. But you do need to contact Social Security about 3 months before your 65th birthday so we can help you sign up for Medicare. IF YOU'RE A GOVERNMENT EMPLOYEE OR RETIREE Government employees or retirees who are eligible for Medicare because of government work should contact Social Security about 3 months before their 65th birthday to apply for hospital insurance. IF YOU'RE DISABLED AND UNDER 65 You will automatically get the same Medicare enrollment package described on page 8, (see paragraph "If You Are Already Getting Social Security Or Railroad Retirement Checks") about 3 months before you become eligible for Medicare. You become eligible after you have been entitled to disability benefits for 24 months. IF YOU'RE A DISABLED WIDOW OR WIDOWER BETWEEN 50 AND 65 If you're a disabled widow or widower between 50 and 65--but you haven't applied for disability benefits because you're already getting another kind of Social Security benefit--you may be able to get hospital insurance. If you are disabled, contact Social Security as soon as you can so that you don't lose out on any Medicare protection. -------------------------------------------------------------------------- Page 10 IF YOU'RE A GOVERNMENT EMPLOYEE AND YOU BECAME DISABLED BEFORE 65 You may be able to get Medicare based on your work in government. Generally, there is a 29-month waiting period before hospital insurance benefits can start. But please don't wait to contact Social Security. Get in touch with us right away so that you don't lose out on any Medicare protection. IF YOU'RE 65 BUT DON'T QUALIFY FOR MEDICARE HOSPITAL INSURANCE If you're 65 or over, but don't meet any of the circumstances described above, you do have an option. You can choose to buy the coverage, much like you buy private insurance, for a monthly premium. But if you want to buy hospital insurance, you also have to enroll in Medicare medical insurance and pay a monthly premium for that coverage as well. (If you are an alien, you must be a lawfully-admitted permanent resident and must live in the U.S. for 5 years before you can buy Medicare.) If you choose to buy hospital insurance coverage, the enrollment periods are the same as described for medical insurance on page 12. IF YOU'RE UNDER 65 AND USED TO BE ENTITLED TO DISABILITY INSURANCE BENEFITS AND MEDICARE If you used to get disability insurance benefits and Medicare but you lost those benefits solely because you were working, and if you're still disabled, you can buy Medicare coverage in much the same way as described for those age 65 or over. But you don't have to enroll in Medicare medical insurance if you choose not to do so. -------------------------------------------------------------------------- Page 11 IF YOU, YOUR SPOUSE, OR YOUR DEPENDENT CHILD HAS PERMANENT KIDNEY FAILURE Contact Social Security to see if you are eligible for Medicare. GETTING MEDICARE MEDICAL INSURANCE PART B) Unlike Medicare hospital insurance, you have to pay a monthly premium for Medicare medical insurance. Since there's a monthly premium, you need to decide whether or not you want to enroll. One Special Note: Many of the services needed by people with permanent kidney failure are covered only by the medical insurance part of Medicare. Here's the way enrollment works. IF YOU'RE GETTING SOCIAL SECURITY OR RAILROAD RETIREMENT BENEFITS In the section on signing up for hospital insurance, we explained that you will get an "enrollment package" 2 or 3 months before you become eligible for Medicare. That package tells you that you'll be automatically enrolled in both parts of Medicare. But, because there's a monthly premium for medical insurance, you have the option to turn it down. You would still get hospital insurance. (Complete instructions are given in the packet, and you can call Social Security or your railroad retirement office if you have questions.) -------------------------------------------------------------------------- Page 12 IN OTHER SITUATIONS You need to contact Social Security to apply for medical insurance if you: * do not file for hospital insurance at 65 because you plan to continue working past 65; or * had medical insurance coverage in the past, but dropped the coverage; or * turned down medicalinsurance when you became entitled to hospital insurance; or * are 65 but you aren't eligible for hospital insurance; or * are eligible for Medicare based on government work; or * have permanent kidney failure; or * are a disabled widow or widowerbetween 50 and 65 and you aren't getting disability benefits; or * live in Puerto Rico or outside the U.S. WHEN YOU CAN SIGN UP FOR MEDICAL INSURANCE You should know that you have only a specific period of time to decide if you want medical insurance coverage. Here's how it works. INITIAL ENROLLMENT PERIOD When you are about to become eligible for medical insurance, you have 7 months to sign up. This 7-month period begins 3 months before the month you first become eligible and ends 3 months after that month. If you enroll during the first 3 months, your medical insurance will start with the month you actually become eligible; there is no delay. If you enroll during the last 4 months, your coverage will start 1 to 3 months after you sign up. -------------------------------------------------------------------------- Page 13 GENERAL ENROLLMENT PERIOD What happens if you don't sign up during the initial enrollment period, but later change your mind? You are given another chance to sign up each year. This general enrollment period runs from January 1 through March 31 of each year. But if you enroll during the general enrollment period, your insurance coverage won't start until the following July. Also, your monthly premium will be 10 percent higher for each 12-month period you could have been enrolled, but weren't. (This limit on when you can enroll and the 10-percent increase in premiums might not apply if you have employer group health coverage--pages 26-27.) A SPECIAL NOTE ABOUT HEALTH MAINTENANCE ORGANIZATIONS Most Medicare beneficiaries have a choice about how and where to receive their Medicare-covered services. One way is to choose a particular doctor or hospital approved under Medicare. In this case, the bill will be sent in to Medicare after the service is provided. You are responsible for any amounts that Medicare does not cover. (If you have "Medigap" insurance, it may help pay these charges.) Another way is to sign up for a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP). HMOs and CMPs provide health care in exchange for a monthly, fixed fee. Medicare beneficiaries then get all Medicare-covered hospital and medical insurance benefits through the plan. Your costs are known in advance and are generally limited to the fixed monthly premiums and minimal "copayments." (A copayment is a set amount that the beneficiary is required to pay for each service.) -------------------------------------------------------------------------- Page 14 Some HMOs and CMPs provide services beyond what Medicare covers, such as prescription drugs or hearing aids, at no extra cost to you. But most also have some limits on your care that you should know about before you enroll. Your Social Security office can tell you how to contact an HMO or CMP in your area if you want more information. SECTION 4--WHAT DOES MEDICARE COVER? The two parts of Medicare are designed to help pay for different kinds of health care costs. And there are some kinds of health care that aren't covered by Medicare at all. We'll look first at what is covered under Medicare hospital insurance or Medicare medical insurance. In the next section, we'll tell you what isn't covered. You can get specific information about Medicare costs, deductibles, and "coinsurance" rates by calling Social Security. MEDICARE HOSPITAL INSURANCE Medicare hospital insurance can help pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care, and hospice care. Each of these is described in more detail below. BENEFIT PERIODS Before you read the sections below, you need to understand what we mean by "benefit period," which is a term we use when we explain what Medicare hospital insurance covers. -------------------------------------------------------------------------- Page 15 A benefit period starts the day you enter a hospital. It ends when you have been out of the hospital (or other facility primarily providing skilled care) for 60 days in a row. If you remain in a facility (other than a hospital) that primarily provides skilled care, a benefit period ends when you have not received any skilled care there for 60 days in a row. There is no limit to the number of benefit periods you can have for hospital and skilled nursing facility care. But special limits do apply to hospice care. (See "Hospice Care," page 17.) INPATIENT HOSPITAL CARE If you need inpatient care, hospital insurance helps pay for up to 90 days in any Medicare-participating hospital during each benefit period. Hospital insurance pays for all covered services (see the next page) for the first 60 days, except for a deductible. For days 61 through 90, hospital insurance pays for all "covered services" except for a daily coinsurance amount. (Coinsurance is the portion of the bill that the beneficiary is required to pay even after the deductible is met.) If you are out of the hospital for at least 60 days in a row, and then go back in, you will start a new benefit period. This means that your 90 days of coverage will start all over again, with the same rules as above. What if you need more than 90 days of inpatient care during any benefit period? You can decide to use some or all of your "reserve days." Reserve days are an extra 60 hospital days you can use if you have a long illness and have to stay in the hospital for more than 90 days. You have only 60 reserve days in your lifetime, and you can decide when you want to use them. For each reserve day you use, hospital insurance pays for all covered services except for a daily coinsurance amount. -------------------------------------------------------------------------- Page 16 Here are examples of what Medicare hospital insurance pays for when you're in a hospital: * semi-private room and all meals * regular nursing services * operating and recovery room * intensive care and coronary care * drugs, lab tests, and X-rays * medical supplies and appliances * rehabilitation services, such as physical therapy * preparatory services related to kidney transplant surgery SKILLED NURSING FACILITY CARE If you need inpatient skilled nursing or rehabilitation services after a hospital stay, and you meet certain other conditions, hospital insurance helps pay for up to 100 days in a Medicare-participating skilled nursing facility in each benefit period. Hospital insurance pays for all covered services for the first 20 days. For the next 80 days, it pays for all covered services except for a daily coinsurance amount. Here are examples of what Medicare pays for when you're in a skilled nursing facility: * semi-private room and all meals * regular nursing services * rehabilitation services, such as physical therapy * drugs, medical supplies, and medical appliances NOTE: It is important to point out here that Medicare does not pay for "custodial care" when that is the only kind of care that you need. This is -------------------------------------------------------------------------- P.17 the type of care people often think of when they think of nursing home care. Custodial care is care that could be given by someone who is not medically skilled (for example, help with dressing, walking, or eating). HOME HEALTH CARE If you are confined to your home and meet certain other conditions, Medicare can pay the full approved cost of home health visits from a Medicare-participating home health agency. There is no limit to the number of covered visits you can have. Here are examples of what Medicare hospital insurance pays for when you need home health care: * intermittent skilled nursing care * physical therapy * speech therapy If you need one or more of the covered services, then hospital insurance also covers part-time or intermittent services of home health aides, occupational therapy, medical social services, and medical supplies and equipment. A 20 percent copayment applies to covered durable medical equipment (e.g., wheelchairs and hospital beds). HOSPICE CARE A hospice is a program that provides pain relief and other support services for terminally-ill people. Medicare hospital insurance can help pay for hospice care for terminally-ill beneficiaries if the care is provided by a Medicare-certified hospice and certain other conditions are met. -------------------------------------------------------------------------- P.18 There are special "benefit periods" that apply to hospice care. Hospital insurance can pay for hospice care for a maximum of two 90-day periods and one 30 day period and one extension period of indefinite duration when the patient is terminally ill. Here are examples of what Medicare hospital insurance covers when you need hospice care: * doctors' services and nursing services * medical appliances and supplies, including outpatient drugs for relief of pain * physical and speech therapy * home health aide and homemaker services * medical social services * counseling * respite care (short-term inpatient care to give temporary relief to the person who normally assists with home care of the patient) Hospital insurance pays almost all of the cost of outpatient drugs and inpatient respite care. And it pays the full cost for all other covered services. MEDICAL INSURANCE BENEFITS Medicare medical insurance helps pay for your doctor's services and many other medical services and supplies that are not covered by the hospital insurance part of Medicare. DEDUCTABLE Each year, before Medicare medical insurance begins paying for covered services, you must meet the annual medical insurance "deductible." (A deductible is the amount a beneficiary must pay before Medicare begins paying.) -------------------------------------------------------------------------- Page 19 After you meet that deductible, Medicare will generally pay 80 percent of the approved charges for covered services during the rest of the year. DOCTORS' SERVICES Medical insurance covers services you receive from a doctor. Here are some examples of doctors' services covered by Medicare: * medical and surgical services, including anesthesia * diagnostic tests that are a part of your treatment * X-rays * radiology and pathology services by doctors while you are a hospital inpatient or outpatient * limited treatment of mental illness * services of your doctor's office nurse * drugs that cannot be self-administered, blood transfusions, and other medical supplies Here are some examples of other services covered by medical insurance: * outpatient hospital services you receive for diagnosis and treatment of an illness, including care in an emergency room or outpatient clinic of a hospital * home health visits if you don't have hospital insurance and if certain conditions are met * ambulance transportation * home dialysis equipment and support services * outpatient physical/occupational therapy and speech pathology services * radiation treatments -------------------------------------------------------------------------- Page 20 SECTION 5--WHAT MEDICARE DOES NOT COVER Medicare provides basic health care coverage, but it can't pay all of your medical expenses. Here are examples of what Medicare does not pay for: * "custodial care" (This is care that could be given safely and reasonably by a person who is not medically skilled, and which is given mainly to help the patient with daily living. Examples include help with walking, bathing, and dressing. Even if you are in a participating hospital or skilled nursing facility, or you are getting care from a participating home health agency, Medicare does not cover the cost of care if it is mainly custodial.) * most nursing home care * care you get outside the U.S. (but under certain conditions, care in Canada or Mexico might be covered) * dental care and dentures * routine checkups and the tests directly related to these checkups (except that some screening, Pap smears and mammograms are covered) * most immunization shots * most prescription drugs * routine foot care * tests for, and the cost of, eyeglasses or hearing aids * personal comfort items, such as a phone or TV in your room -------------------------------------------------------------------------- Page 21 SECTION 6--YOUR RIGHT TO MAKE HEALTH CARE DECISIONS All Medicare and Medicaid certified hospitals, nursing homes, and other health care providers and organizations are required by law to inform adult patients about their right to make their own health care decisions, including the right to accept or refuse medical treatment. Usually, you will be asked to sign a written statement about how you want future medical decisions to be made if you become incapacitated. There are two common forms of statements. 1. A Living Will states the kind of medical care you want or don't want if you become unable to make your own decisions. 2. A Durable Power of Attorney for Health Care is a signed, dated, and witnessed paper naming another person--such as your husband, wife, son, daughter, or close friend--to make medical decisions for you if you become unable to make them for yourself. When you enter a Medicare or Medicaid health care facility, be sure you receive information about these rights. In general, you may prepare, change, or cancel your decision at any time, in accordance with your State's law. State laws on these provisions vary. -------------------------------------------------------------------------- Page 22 SECTION 7--WHAT IF YOU THINK YOU NEED MORE INSURANCE? As we've seen, Medicare provides basic health care coverage, but it can't pay all of your medical expenses, and it doesn't pay for most long-term care. For this reason, many private insurance companies sell insurance to fill in the gaps in Medicare coverage. This kind of insurance is often called "Medigap" for short. This section explains the types of insurance that are available and gives some tips on what to look for--and look out for. KINDS OF PRIVATE HEALTH INSURANCE There are a number of different kinds of insurance you can buy to cover some or all of the medical costs that Medicare doesn't cover. Here's a brief description of the most common ones: * Medicare Supplement policies pay part or all of Medicare's deductibles and "coinsurance" amounts. (Coinsurance is the portion of the bill that the beneficiary is required to pay even after the deductible is met.) Some also pay for health services that are not covered by Medicare. Federal law has standardized these policies to ten basic plans. To find out what new standardized policies will be available in your State, check with your State insurance department. * Major Medical Expense policies help cover the high cost of serious illness or injury, including some health services not covered by Medicare. They usually have a large deductible and may not cover Medicare's deductibles and coinsurance amounts. -------------------------------------------------------------------------- Page 23 * Employer Group Insurance coverage can sometimes be continued or converted to a suitable individual Medicare-supplement policy when you reach age 65. Some also offer benefits to the spouse. (This kind of insurance is explained more fully in section 8.) * Association Group Insurance is offered by many organizations to their members over age 65. Some insurance policies are designed to offer a particular kind of coverage. For example: * Nursing Home Coverage usually pays a certain amount per day for services provided in a skilled nursing facility. * Hospital Confinement Indemnity Coverage pays a fixed amount for each day you're in the hospital, up to a specified maximum number of days. * Specified Disease Coverage (not available in some States) provides benefits only if you become ill because of a particular disease, such as cancer. Benefits are usually limited to a certain dollar amount. SHOPPING FOR PRIVATE HEALTH INSURANCE Buying insurance can be intimidating. There are many different kinds of insurance to choose from, and many things to consider. Here are some important tips. Shop carefully. Contact several different companies and compare the coverage and cost of insurance. Understand what you're buying. Go over each policy carefully to see if it gives you the kind of coverage you need. Make sure you know what the policy covers. Policies from different companies may sound like they offer the same coverage, when in fact they don't. For example, each may say it pays for "skilled nursing care," but each policy may define the term differently. -------------------------------------------------------------------------- Page 24 Don't buy more insurance than you need. Does the policy pay a set dollar amount, or a percentage of the cost of care? With inflation, policies that pay a fixed dollar amount lose relative value over time. How long will the coverage last? Some policies provide benefits for a certain length of time most commonly, up to 1 year. Others pay for the rest of the policyholder's life. What isn't covered? Always check for waiting periods and "pre-existing condition" exclusions. These exclusions mean that a policy will not pay for treatment of a medical condition you already have. And often, insurers won't pay benefits for treatment of mental illness, alcoholism or drug addiction, etc. How much does nursing home care cost in your area? Before buying a policy, get an idea of the cost of nursing home care and home health care in your area. Otherwise, you won't be able to tell if your coverage would be adequate. Check your right to renew the policy. Policies that renew automatically offer the best protection. Beware of scams. Don't believe anyone who tells you that he or she is from the Government, and tries to sell you insurance. Policies to supplement Medicare are not sold or serviced by the Medicare program or any other State or Federal Government agency. Also, it is illegal for any insurance company or agent to knowingly sell you a policy that duplicates Medicare coverage or your private health insurance coverage. Companies or agents that break this law are subject to Federal penalties. (If you think you have been the victim of an illegal insurance sales practice, contact your State insurance department or call the U.S. Department of Health and Human Services, toll-free, at 1-800-638- 6833.) -------------------------------------------------------------------------- Page 25 Take your time. Don't let a salesperson pressure you, and never pay the agent in cash. Allow yourself enough time to make an informed decision. And when your policy arrives, read it to make sure it gives the coverage you ordered. SECTION 8 WHAT YOU SHOULD KNOW IF YOU HAVE OTHER HEALTH INSURANCE As we've explained, Medicare hospital insurance is free, but you pay a monthly premium for medical insurance. If you already have other health insurance when you become eligible for Medicare, is it worth the monthly premium cost to sign up for Medicare medical insurance? The answer varies with the individual and the kind of other health insurance. Although we can't give you "yes" or "no" answers, we can offer a few tips that may be helpful when you make your decision. IF YOU HAVE A PRIVATE INSURANCE PLAN Get in touch with your insurance agent to see how your private plan fits or "integrates"--with Medicare medical insurance. This is especially important if you have family members who are covered under the same policy. And remember, just as Medicare doesn't cover all health services, most private plans don't either. In planning your health insurance coverage, be mindful that most nursing home care is not covered by Medicare or private health insurance policies. One important word of caution: For your own protection, don't cancel any health insurance you now have until your Medicare coverage actually begins. -------------------------------------------------------------------------- Page 26 IF YOU HAVE HEALTH INSURANCE FROM AN EMPLOYER GROUP HEALTH PLAN In this case, there are some special rules you should know about. If you work past 65--or are 65 or older and the spouse of a worker of any age and are covered under an employer group health plan, you can wait to enroll in Medicare medical insurance during a 7-month "special enrollment period." This period begins with the month the group health coverage ends, or the month employment ends--whichever comes first. If you meet certain requirements, you won't have to wait for a general enrollment period, and you won't have to pay the 10-percent premium surcharge for late enrollment in Medicare. Group health plans of employers with 20 or more employees are required by law to offer workers who are 65 (or older) the same health benefits that are provided to younger employees. They must also offer the spouses who are 65 (or older) , of workers of any age the same health benefits given younger spouses. If you are 65 or older and continue working--or you are 65 or older and you are the spouse of the worker--and you accept the employer's health insurance plan, Medicare will be the "secondary payer." This means that the employer plan pays first on your hospital and medical bills. If the employer plan does not pay all of your expenses, Medicare may pay secondary benefits. On the other hand, if you reject the employer's health plan, Medicare will be the primary health insurance payer. The employer is not allowed to offer you Medicare supplemental coverage if you reject his or her health plan. -------------------------------------------------------------------------- Page 27 If you are under 65 and disabled, you are an employee or the family member of an employee, and you have health coverage under a "large group health plan," Medicare will be the secondary payer. A large group health plan is one that covers employees of at least one employer who has 100 or more workers. If that's the case, you will also have special enrollment period and premium rights that are similar to those for workers 65 or older. If you are under 65, entitled to Medicare because of permanent kidney failure, and have employer group health coverage, Medicare will be the secondary payer for the first 18 months of your Medicare Part A eligibility or entitlement. At the end of the 18-month period, Medicare becomes your primary payer. IF YOU HAVE HEALTH CARE PROTECTION FROM THE DEPARTMENT OF VETERAN'S AFFAIRS (DVA) OR CHAMPUS OR CHAMPVA PROGRAM In this case, your health benefits may change or end when you become eligible for Medicare. You should contact the DVA, Department of Defense, or a military health benefits advisor for information before you decide whether or not to enroll in Medicare medical insurance. -------------------------------------------------------------------------- Page 28 IF YOU HAVE HEALTH CARE PROTECTION FROM THE INDIAN HEALTH SERVICE, A FEDERAL EMPLOYEE HEALTH PLAN, OR A STATE MEDICAL ASSISTANCE PROGRAM If this is your situation, you should contact the people in those offices. They can help you decide whether it is to your advantage to have Medicare medical insurance. QUESTIONS? We've covered a number of difficult rules in this chapter. If you are not sure if any apply to you, contact Social Security for help. (But if you aren't sure about the size of the employer group health plan, check with the personnel office or the employer.) -------------------------------------------------------------------------- Page 29 SECTION 9--WANT MORE INFORMATION? It's difficult to summarize a program as complex as Medicare in a single booklet. If you have other questions about Medicare, please contact Social Security. You can do this by visiting one of our offices, writing to us, or calling our toll-free number, 1-800 772-1213. You can call from 7:00 a.m. to 7:00 p.m. any business day. The Social Security Administration treats all calls confidentially--whether they're made to our toll-free number or to one of our local offices. We also want to ensure that you receive accurate and courteous service. That is why we have a second Social Security representative listen to some incoming and outgoing telephone calls. -------------------------------------------------------------------------- Page 30 OTHER BOOKLETS AVAILABLE The Social Security Administration produces many other publications and fact sheets to give you information about other parts of the Social Security program. You can get a free copy of these publications from any Social Security office. Here's a list of some of the publications we have available. * Understanding Social Security (Publication No. 05-10024--A brief overview of each of the Social Security programs * Retirement (Publication No. 05-10035--A guide to Social Security retirement benefits * Disability (Publication No. 05-10029--A guide to Social Security disability benefits * Survivors (Publication No. 05-10084--A guide to Social Security survivors benefits * SSI (Publication No. 05-11000-A guide to the SSI program All of these publications, including this one, are available in Spanish. -------------------------------------------------------------------------- Page 31 Index Page Subject benefit period.......................................14-15 CHAMPUS/CHAMPVA health insurance ............................27 coinsurance..................................................15 competitive medical plans....................................13 copayment....................................................13 covered services.............................................14-19 --doctors' services..........................................19 --home health care...........................................17 --hospice care ..............................................17-18 --hospital inpatient.........................................15 --hospital outpatient .......................................19 --skilled nursing facility ..................................16 custodial care...............................................16,20 deductible...................................................18 doctors'services.............................................19 eligibility..................................................4-6 --hospital insurance.........................................4-6 --medical insurance..........................................6 employer group health plans..................................26-27 enrollment...................................................8-14 --general enrollment period..................................13 --hospital insurance.........................................8-11 --initial enrollment period..................................12 --medical insurance..........................................11-12 -------------------------------------------------------------------------- Page 32 SUBJECT Page health maintenance organizations ............................13-14 home health care.............................................17 hospice care ................................................17-18 hospital care ...............................................14-16 --inpatient..................................................15-16 --outpatient.................................................19 --kidney failure, benefits for victims of....................5-6,11 living will..................................................21 Medicaid ....................................................4 Medicare hospital insurance..................................14 Medicare medical insurance ..................................18 Medigap policies ............................................22-23 non-covered services.........................................20 Part A Medicare..............................................3 Part B Medicare..............................................3 power of attorney ...........................................21 private health insurance.....................................22-25 --types of...................................................22-23,25-28 --tips when shopping for.....................................23-25 QMB Program..................................................7 reserve days.................................................15 respite care.................................................18 secondary payer, Medicare as ................................26 Veteran's Affairs, Department of ............................27 U.S. department of Health and Human Services Social Security Administration SSA Publication No. 05-10043 January 1992 ICN 460000 U.S. Government Printing Office 1992 -- 312-168/60011