Understanding Medicare Coverage
2006

What Is Medicare?

Medicare is a federal health insurance program for people 65 years or older, certain people with disabilities and people with permanent kidney failure treated with dialysis or a transplant. Medicare consists of two parts. Part A is hospital insurance and Part B is medical insurance.

Part A helps to cover your inpatient care in hospitals, critical access hospitals, skilled nursing facilities, hospice care and some home health care. This coverage requires cost sharing such as coinsurance and deductibles. In most cases, there are no costs for the services.

Part B helps to cover your doctor's services and outpatient hospital care. It also covers additional services such as physical or occupational therapies, when they are deemed medically necessary. This coverage requires a monthly premium of $88.50 for the year 2006, as well as 20% of most fees after individuals meet an annual deductible.

Enrolling in Part B is your choice. If you already receive Social Security or Railroad Retirement benefits, then you are automatically enrolled starting the first day of the month you turn 65. If you are disabled, you are enrolled in Part B after you receive Social Security or Railroad Retirement benefits for 24 months. If you do not want Part B coverage, follow the instructions that come with the card mailed to you after the above conditions are met.

Medicare Part D plans are different in every state. The average premium for Part D is $32 per month and the average deductible is $250 per year. For the plans offered in your state please call 1-800-Medicare or visit your local pharmacy.

Paying for Medicare Premiums

If the costs of Medicare premiums are too high for limited income persons, the state has established four programs to help individuals afford Medicare services. Applications for these programs can be filled out at the local office of the Rhode Island Department of Human Services. To find the local office near you call 401-462-5300, TTY: 401-462-3363, or 800-964-6211

1. The Qualified Medicare Beneficiary Program (QMB): In this program the state pays for both the Part A premium (if necessary) and the Part B premium, if an individual has a monthly income under $798, or $1,070 for a couple.
   
   
2. The Specific Low-Income Medicare Beneficiary Program (SLMB): In this program the costs of Medicare medical insurance (Part B) premiums are covered if an individual has a monthly income under $957. Married couples' combined income must be under $1,283 per month to qualify.
   
   
3. Qualifying Individuals-1 Program (QI-1): In this program, the costs of the Part B premium are covered for individuals whose income is under $1,077 per month. Married couples' combined income must be under $1,444 per month to qualify.
   
   
4. Qualifying Disabled Working Individuals (QDWI): In this program, the costs of the Part A premium are covered, but not Part B. The individual must be a disabled worker under age 65 who lost Part A because of a return to work. The individual must have an income under $1,695 a month with resources below $4,000. For a couple, the income must be below $2,245 a month with resources below $6,000.
   
   

Expenses Medicare Does Not Cover

Generally speaking there are five costs not covered by Part A and Part B of Medicare coverage.

1. If you are admitted to a hospital, you must pay the first $952 (deductible for Part A). You are also responsible for paying $238 daily for days 61 through 90 of a hospital stay and $476 daily for days 91-150.
   
   
2. If you need skilled nursing or rehabilitation in a skilled nursing facility, you must pay $119 daily from days 21 through 100 of a covered stay.
   
   
3. You have to pay the first $124 a year (deductible for Part B) for the allowable cost of medical services such as doctors' visits, etc.
   
   
4. You have to pay 20% (coinsurance for part B) of the approved charges for medical services after you meet the $124 deductible.
   
   
5. The following are medical expenses not covered by Medicare: hearing aids and eyeglasses, personal or custodial care in nursing homes, the cost of medical services above what is considered allowable by Medicare, routine dental care, private duty nursing and homemaker services, the first three pints of blood taken if they are not replaced.
   
   

To find coverage for these services individuals may buy a Medigap Policy through a private health insurance company. These policies fill the "gaps" in the Original Medicare Plan and they must follow federal and state laws. The front of the Medigap Policy must state that it is "Medicare Supplemental Insurance."

For more information on Medigap call: 1-800-MEDICARE
(1-800-633-4227).

Medicare Health Plans

The different options you have for getting your Medicare benefits are called Medicare Health Plans. The options are the Original Medicare Plan and the Medicare + Choice plan, which includes Medicare managed plans (HMOs and PPOs) and fee-for-service plans.

When choosing a plan you need to look at what plans are available in your area and consider the following:

• Cost - What will your out-of-pocket expenses be?
  
  
• Benefits - Do you need extra benefits and services, like hearing aids, eyeglasses, and routine physical exams and so on?
  
  
• Doctor Choice - Can you see the doctor you want to see? Do you need a referral to see a specialist?
  
  
• Convenience - Where are the doctor's offices and what are their hours? Do you have to file claims yourself? Is there a telephone hotline for medical advice from a nurse or other medical staff?
  
  

To help individuals choose which program is right for them,
the two health plans can be compared at:

http://www.medicare.gov on the web.

Or, call 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048.

How to find out if you have Medicare Coverage:

You must call the Social Security Administration at (800) 772-1213
or contact the local Social Security Office to verify your Medicare
Part A and Part B coverage. The offices in Rhode Island are:

Providence

380 Westminster Street, 3rd Floor
Providence, RI 02903
(401) 528-4501
TTY (401) 273-6648

Woonsocket

U.S. Post Office Building
127 Social Street
Woonsocket, RI 02895
(401) 766-8423
TTY (401) 765-1620

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