1999 Medicare In A Nutshell

Custodial care (type of care that most person at home or in nursing home require) is not covered by Medicare or Medigap policies. The only home care or nursing home care that Medicare covers is skilled-nursing care or skilled-rehabilitation care. Long--term care insurance or Medicaid are alternative sources for paying for custodial-care services.

Medicare program is a system of health insurance for aged and disabled. It consists of two basic parts: Part A provides coverage for costs incurred by eligible beneficiaries for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care and hospice services; Part B is a voluntary program in which eligible beneficiaries who pay a monthly premium are entitled to reimbursement for physician and other medical services and supplies.

Eligibility

Primary Medicare eligibility is linked to eligibility for Social Security retirement and disability benefits. Disabled persons and disabled widows/ widowers under age 65 may also be eligible for Medicare. Some persons who are 65 years of age or older, but not otherwise eligible, may purchase insurance when applying for Soc. Security.

Enrollment

The initial enrollment period begins three months prior to the month of your 65th.birthday and continues three months after that. (There are substantial penalties for late enrollment.) A special period is available to the working aged and their spouses who delay enrollment because of primary, employer based insurance.

Benefits-Medicare Part A

Inpatient Hospital Coverage:

Hospital Insurance (Part A) will pay for all medically necessary inpatient hospital care for the first sixty days minus a deductible of $768 (1999) for each benefit period. For remaining days a beneficiary must pay substantial copayments, which may be covered under a Medigap policy (see below).Major in-hospital services covered by Medicare Part A include a semiprivate room, all meals, special-care units including intensive-care unit, coronary-care unit regular nursing services and drugs furnished by hospital during patient's stay.

Skilled Nursing Facility Care: Medicare will also pay for up to 100 days in a skilled-nursing facility. First 20 covered, but for days 21 through 100 a $96 (1999) daily co-payment is required. Patient must have been hospitalized for 3 days and be admitted to facility generally, within thirty days after leaving the hospital.

Home Health Care: Medicare also provides homehealth care services which can continue for as long as the beneficiary is under a physician's plan of care, requires skilled nursing care and is essentially confined to home. Physical, occupational and speech therapy and the services of a home-health aide are available. A prior hospital stay is not required.

Hospice Care: Medicare's hospice program includes both home care and inpatient care, when needed, and a variety of services not otherwise provided by Medicare. To be eligible, a Medicare beneficiary must be certified by a physician as terminally ill with a life expectancy of approximately six months or less. Those who choose hospice care receive non-curative medical and support services for their terminal illness. Regular Medicare continues to pay, for medical treatments not related to the terminal illness.

Benefits - Medicare Part B

Medicare insurance (Part B) covers a variety of medical services of particular importance to Medicare beneficiaries, including physician services in out of hospital, durable medical equipment, outpatient hospital services physical occupational and speech therapy ambulance transportation. Part B coverage is voluntary. Most Medicare beneficiaries decide to enroll in program with their monthly premiums of $45.50(1999) and an annual deductible amount of $100 which must be paid before Medicare benefits are reimbursed. Medicare pays 80% of the approved charge for services and beneficiary is responsible for the 20% co-payment. The 80% payment usually amounts to 60% of actual medical bill.

Excluded Services under Part A and Part B

Services not covered by Medicare Part A are private duty nursing and, generally, a private room. Other services excluded under Medicare Part B are most outpatient prescription drugs which do not require admin. by a physician, routine physical checkups, immunization with some exceptions, eyeglasses or contract lenses, most dental care and hearing aids. Generally, Medicare will not pay for hospital or medical services abroad or physician services on ship cruises beyond U.S. territorial waters

Limiting Charge

There is cap on what doctors charge Medicare patients for each service. In NY, doctors may not charge more than 5% above Medicare approved rate for most services.

Medigap Insurance