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The A-B-C’s of Medicare… a Starter’s Guide
Medicare Basics
Provided by Amy Farmer, Admissions Director
Heartland of Greenville
Let’s face it - Medicare can be confusing, both for those who are
enrolled in the program and for those who are assisting loved ones in
managing their health care needs. Fortunately, help is
available! The Ohio Senior Health Insurance Information Program
(OSHIIP) is a program of the Ohio Department of Insurance. Since 1992,
OSHIIP’s trained staff and network of more than 1,300 volunteers
throughout the state have been educating consumers about
Medicare.
Last fall, my grandmother approached me for help in understanding her
options for Medicare Part D, the prescription drug plan. The
process of researching plans was more difficult than I expected, and I
committed at that time to learn as much as I could about Medicare so I
could be a resource for my family and friends.
The OSHIIP volunteer program trains individuals to counsel those in
their communities who need help understanding their Medicare
options. It includes 22 hours of classroom training in Columbus,
as well as access to resources and publications to assist in providing
information to the community.
As the Darke County OSHIIP Coordinator, I am available to answer your
questions about Medicare coverage and options for yourself or a loved
one. There is no cost for this service, and I can be reached at
Heartland of Greenville at 937-548-3141 or by email at
3241admiss@hcr-manorcare.com.
Below are some frequently asked questions about Medicare from the Ohio
Department of Insurance website.
What is the difference
between Medicare and Medicaid?
Medicare is federal health insurance for people age 65 or older, under
65 with certain disabilities and any age with End Stage Renal Disease
(permanent kidney failure) requiring dialysis or a kidney transplant.
Medicaid is a medical assistance program for low-income people. It is
jointly funded by the federal government and the states, and its
benefits vary from state to state. Most health care costs are covered
if you qualify for both Medicare and Medicaid.
What are my Medicare
coverage options?
Medicare patients have two options in receiving their Medicare
benefits: either through Original Medicare or a Medicare Advantage
plan. Your out-of-pocket costs vary depending on your plan, coverage
and the services you use.
Original Medicare contains what is called Part A (hospital) and Part B
(medical) coverage. You can choose to purchase additional insurance
such as Medicare supplement insurance (also known as MedSup or Medigap)
and Part D prescription drug coverage. Medicare supplement insurance
and prescription drug coverage each require a monthly premium in
addition to your Part B premium.
Medicare Advantage plans are options approved by Medicare but run by
private companies. They are part of the Medicare Program. With Medicare
Advantage plans you generally get all your Medicare-covered health care
through that plan. Coverage can include prescription drug coverage. You
may get extra benefits, such as coverage for vision, hearing, dental,
and/or health and wellness programs. You may have to use the plan's
doctors and hospitals to get services. You don't need to buy a Medigap
policy. These plans may require a monthly premium in addition to your
Part B premium.
Am I eligible for Medicare?
Generally, you are eligible for Medicare if you or your spouse worked
for at least 10 years in Medicare-covered employment and you are 65
years or older and a citizen or permanent resident of the United
States. If you are not yet 65, you might also qualify for coverage if
you have a disability or have End-Stage Renal Disease (permanent kidney
failure requiring dialysis or transplant).
Most people on Medicare pay a premium for Part A. However, you can get
Part A at age 65 without having to pay premiums if:
• You already get retirement benefits from Social
Security or the Railroad Retirement Board.
• You are eligible to get Social Security or Railroad
benefits but you haven't yet filed for them.
• You or your spouse had Medicare-covered government
employment.
• If you are under 65, you can get Part A without
having to pay premiums if you have:
• Received Social Security or Railroad Retirement
Board disability benefits for 24 months.
• End-Stage Renal Disease and meet certain
requirements.
•
While you do not have to pay a premium for Part A if you meet one of
these conditions, you must pay for Part B if you want it.
How do I enroll in Medicare?
For some, enrollment is automatic. If you begin receiving Social
Security income prior to age 65 or you receive Social Security
disability income, your enrollment is automatic. Everyone else must
apply through the Social Security Administration.
Those turning age 65 have a total of seven months to enroll. Your
Medicare enrollment period starts three months before the month of your
65th birthday. Your enrollment period ends three months after the month
of your 65th birthday. If you apply before your birth month, your
Medicare coverage should start on the first day of your birth month.
If you don't enroll in Medicare during your initial seven-month
enrollment period, you must wait to apply during the next general
enrollment period (January through March each year). You may also owe a
10 percent penalty on your Part B premium for each year you delay Part
B.
Where can I sign up for
Medicaid?
Contact your county Department of Job and Family Services for the
proper paperwork to apply for this program. You can visit
www.jfs.ohio.gov/ohp for helpful information.
Why do I need Medicare
supplement insurance?
Original Medicare does not pay all medical expenses. A Medicare
supplement policy, also known as MedSup or Medigap insurance, fills
most of Medicare’s coverage gaps. You can choose from many standardized
plans that cover various costs.
Are there Medicare
Advantage plans in my county?
Each year, private companies offering Medicare Advantage plans must
apply to the federal government and meet requirements in order to offer
their plans in your area. Some companies choose not to re-apply. That's
why it's important to review your options every fall.
Does Medicare cover
diabetic supplies?
Medicare covers test strips, lancets, the machine used to test blood
sugar levels and outpatient self-management education. It also covers
replacement batteries and calibration solution for the machines that
require it. Medicare also covers diabetic shoes.
Does Medicare cover care
in a nursing home?
You may be covered for short stays in a skilled-care facility. You must
meet certain pre-entrance requirements in order to qualify for
benefits. Medicare does not cover long-term care in a nursing home. If
you’re eligible, Medicare will cover skilled care for the first 20 days
and a certain amount each day for days 21-100. After 100 days per
benefit period, Medicare pays nothing.
Does Medicare cover home
health care?
Yes, but only if your doctor orders part-time skilled care and you are
homebound. If you meet Medicare’s requirements for home health care, it
is paid at 100 percent.
Will Medicare pay for
outpatient prescriptions, hearing aids, dentures, eyeglasses, etc.?
Original Medicare (Part A and Part B) covers very little with regards
to prescription medication. Medicare Part D, which was introduced in
2006, is Medicare’s prescription drug benefit. This benefit is
available through stand-alone plans or through most Medicare Advantage
plans.
Original Medicare also does not cover hearing aids, dental procedures
or routine eye exams. Some Medicare Advantage plans will provide some
coverage for these extra benefits.
Does Medicare pay for
physical therapy?
Yes, Medicare Part B pays 80 percent of the approved amount for
outpatient physical therapy up to a maximum. Medicare Part A may also
cover physical therapy during inpatient stays.
Can my doctor insist that
I pay up front for services before Medicare pays?
Yes, but only if your doctor doesn't accept assignment. If your doctor
doesn't accept assignment, he or she cannot charge you more than the
Medicare approved amount. If your doctor participates with Medicare, he
or she can collect the deductible and copayment.
Who qualifies for Medicaid?
Medicaid is available only to certain low-income individuals and
families who fit into an eligibility group that is recognized by
federal and state law. Medicaid does not pay money to you; instead, it
sends payments directly to your health care providers. See above for
enrollment and program information.
Do I need long-term care
insurance?
That’s a decision only you can make. You should consider your assets,
life expectancy, current health, lifestyle, family health history and
family support. Please call OSHIIP at 1-800-686-1578 if you have
specific questions or read our consumer's guide to long-term care
insurance.
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