No one
enjoys paying taxes, but you can take some satisfaction in the fact that
some of your hard-earned money goes to two government programs that provide
essential health protection for a fraction of what you’d pay for
private insurance. These government-sponsored plans help ensure that almost
everyone who is older than 65 — and those who are disabled, regardless
of age — gets the basic health coverage they need.
Medicare is the nation’s largest health
insurance program, covering 39 million Americans (35 million aged 65
and older). It gives coverage
regardless of what your income is.
However, Medicare doesn’t provide complete protection. "The
main limitation is the lack of coverage for prescription medications
and long-term care services. Dental care is not covered either," says
Judith Kasper, Ph.D., professor of health policy and management at Johns
Hopkins School of Public Health. That’s why people who enroll in
Medicare purchase supplemental insurance as well, when they can afford
it.
.
One Plan, Two Parts
Under Medicare, you’re actually getting
two different plans: Medicare Part A and Medicare Part B. Each part
covers different things (and has
different requirements), so you need to know the differences.
Here’s what you get from
Medicare Part A:
You are covered for up to 90 days of inpatient
hospital care during each "benefit period." A benefit period is measured from the
time you start receiving care to the time you leave the hospital. There’s
no limit to the number of benefit periods. You may also be eligible for
home health care, hospice care or short-term treatment in a skilled nursing
facility following a hospital stay.
And here’s what you get
from Medicare Part B:
1.Doctors’ fees
2. Outpatient hospital services, including emergency room visits
3. Diagnostic tests
4. Some preventive care, such as mammograms, colon cancer screening, flu and
pneumonia
5. Vaccinations and diabetes self-management
6. Special medical equipment, such as wheelchairs
Medicare Part B typically covers only a part of these costs. You may
be responsible for making a co-payment, usually 20 percent of the amount
approved by Medicare.
Getting Into The Program
You’re eligible for Medicare as long as
you (or your spouse) is 65, have worked for at least 10 years and have
paid payroll taxes. You
may also be covered if you have a permanent disability, regardless of
your age.
You will receive an enrollment notice in the mail
about three months before your 65th birthday. Or you can contact your
local Social Security
office to obtain the form. (If you’re already receiving Social
Security or railroad retirement benefits, you’re automatically
enrolled.) Once you fill out the form and send it in, you’re covered
for Part A. That’s all you have to do.
You pay the Medicare Part B premium of $58.70 per month in 2003. This
amount may change January 1, 2003. In some cases this amount may be higher
if you did not choose Part B when you first became eligible at age 65.
The cost of Part B may go up 10% for each 12-month period that you could
have had Part B but did not sign up for it, except in special cases.
You will have to pay this extra 10% for the rest of your life.
Enrolling in part B is your choice. You can sign up for Part B anytime
during a 7-month period that begins 3 months before you turn 65. Visit
your local Social Security office, or call the Social Security Administration
at 1-800-772-1213 to sign up. If you choose to have Part B, the premium
is usually taken out of your monthly Social Security, Railroad Retirement,
or Civil Service Retirement payment. If you do not get any of the above
payments, Medicare sends you a bill for your part B premium every 3 months.
You should get your Medicare premium bill by the 10th of the month. If
you do not get your bill by the 10th, call the Social Security Administration
at 1-800-772-1213, or your local Social Security office. If you get benefits
from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.
Most people go ahead and sign up for Part B. "About 95 percent
of the Medicare population gets Part B," says Dr. Kasper. "Even
if you have other insurance, you’ll still want to get it." It
may cover things that private Medigap main insurance doesn’t.
Apart from turning in the form and making sure
your doctor is a Medicare provider, you’re done. But now, things get a little more complicated.
As with any insurance plan, Medicare doesn’t cover everything.
You’re probably going to need some additional coverage as well.
Medigap — Filling In What
Medicare Misses
Most people who get Medicare also purchase supplemental insurance, called
Medigap. Medigap polices are sold by private firms but are regulated
by the states. There are 10 different Medigap polices, designated by
the letters A to J. The letter A policy provides the most basic coverage,
whereas the letter J policy gives the most protection.
With so many policies to choose from, the coverage varies widely. Benefits
might include:
1. Payment of Medicare deductibles
2. Partial payment of prescription drugs
3. Payment for at-home care
4. Additional coverage for extended hospital or nursing home stays
Choosing a Medigap policy can be time-consuming,
but it’s worth
looking at the different policies closely to make sure you’re getting
the coverage you need.
Incidentally, you won’t need Medigap if you’ve
signed up for a Medicare managed care plan, also known as Medicare
Part C. This
plan helps cover the cost of medications, as well as most of the services
provided by Medigap.
Not Just For The Elderly
The majority of people covered by Medicare are
65 and older, but the program also provides coverage for younger folks
with serious disabilities.
In order to qualify, you must prove that you’re totally and permanently
disabled and unable to work.
The provisions for getting Medicare if you have a disability include:
1. You’ve received Social Security disability
benefits for at least two years.
2. You’ve received disability benefits from the Railroad Retirement
Board.
3. You have fulfilled a five-month Medicare waiting period.
4. You (or your spouse) have permanent kidney failure and receive dialysis
or have had a kidney transplant.
Medicaid — Help For People
With Lower Incomes
Unlike Medicare, which is administered by the federal government, Medicaid
is run by the states. This insurance program is based entirely on financial
need. Most people receiving Medicaid are low-income children and families,
but Medicaid is available to low-income elderly people, to whom it is
particularly important because it covers medications and nursing home
care, says Dr. Kasper.
Although Medicare and Medicaid are separate programs, some people qualify
for both. Coverage from both programs does away with almost all out-of-pocket
health care expenses, because Medicaid pays for monthly Medicare premiums
and co-payments to doctors, plus it covers services that Medicare does
not. People who exhaust their financial resources after an extended illness,
regardless of their age, can turn to Medicaid for help.
As with Medicare, Medicaid covers a wide range of services, including
inpatient and outpatient hospital care, medical supplies, transportation
to services and long-term care.
Additional Info
For more-detailed information about Medicare, you can access medicare.gov or the the Kaiser Family Foundation Web site at www.kff.org also provides
more thorough information about both Medicare and Medicaid.
