Reproduced with permission from the Publications section of the Kansas Department on Aging web site, http://www.agingkansas.org/kdoa.

Medicare is a two-part health insurance program administered by the Centers for Medicare and Medicaid Services (CMS). It is designed to meet some of the hospital and medical costs of senior citizens (age 65 or older) and some disabled persons under age 65.

It is not a comprehensive insurance, and there are some health needs that Medicare does not cover, or partially covers. For example, Medicare doesn`t pay for long-term nursing home care. Medicare will cover short-term skilled nursing care following a hospital stay. A consumer who relies on Medicare alone is exposed to substantial financial risk when certain kinds of health problems occur.

The Kansas Foundation for Medical Care provides oversight of quality of care under Medicare. Contact them at (800) 432-0407 with questions or complaints about the care you received in the hospital.

Who is eligible for Part A (Hospital Insurance), and how much does it cost?

If you fit into one of the following three categories, you are eligible if:

Part A enrollment is automatic for those under 65 and disabled or for kidney patients with end-stage renal disease. If you are not automatically eligible, then you should apply for Part A coverage three months before your 65th birthday. For most people who are eligible, Part A is premium-free.

How do I become eligible for Part B (Medical Insurance), and how much does it cost?

You are eligible for Part B if you are 65 or older; under 65 and disabled; or are a kidney patient with end-stage renal disease, AND are a citizen of the United States or a legal resident for five consecutive years. The cost is $54 per month.

If you are automatically eligible for Part A coverage, you will be enrolled in the Part B coverage, unless you notify the Social Security office you do not want it.

Can I choose to sign up for Part B, if I am not automatically enrolled?

Yes. If you sign up for Part B in the three months before the month in which you turn 65, your coverage will be effective the first of the month in which you turn 65. If you enroll in the month you turn 65, your coverage will be effective the first of the next month. You may still enroll in the three months after the month of your birthday, but your Part B benefits will be delayed 2, 3 or 4 months after your birth month. This seven month enrollment period is called the Initial Enrollment Period.

As an example, if your 65th birthday is in April, you may enroll in Part B during January, February or March and have Part B benefits effective April 1. If you enroll in April, your benefits will be available May 1. If you wait until May, June, or July, your Part B coverage could be delayed until September 1.

If you wait until after the seven-month Initial Enrollment Period, you must wait for a General Enrollment Period, January 1 to March 31 each year. Coverage will not start until the following July 1. The monthly premium could be 10% higher for each 12 month period you wait to sign up for the rest of your life.

What hospital costs does Medicare Part A cover?

Medicare will help pay for the following kinds of health care:

How does the inpatient hospital coverage work?

You must pay a deductible before Medicare will pay. The deductible is $812 and is subject to change each year. Each time you enter the hospital, you must pay a new deductible unless you are still in the same "benefit period." A benefit period starts the day you are admitted to the hospital and ends when you have been out of the hospital or a skilled nursing facility for 60 consecutive days.

Besides the deductible, how much will I owe the hospital after an inpatient stay?

Once the deductible is met, you will not be charged for any Medicare covered services for the first 60 days you are in the hospital. Medicare will require that you pay a $203 per day co-payment for hospital days 61-90. If you are hospitalized over 90 days, you must pay 100% of the costs, unless you choose to use "lifetime reserve days." Co-payment for hospital inpatient days 91-150 (lifetime reserve days) is $406/day.

What expenses are included for payment under Part A?

Basically, Medicare pays every service the hospital bills for except personal and convenience items. Included in the billing from the hospital will be all charges for coronary care, intensive care, surgical room charges, lab services, drugs administered in the hospital, and room charges. Medicare will pay the room charge of a semiprivate room unless a private room is medically necessary, such as for a contagious patient or for intensive care. It is important to note that since the doctors do not bill through the hospital, they are not covered under Medicare Part A. Doctors are paid under Part B of Medicare no matter where you receive their services.

Can I use Medicare Part A to cover a stay in a nursing facility?

Medicare will not pay for long-term nursing facility care, but does provide for short-term recuperative stays. After you have been an inpatient in a hospital for three consecutive days, you may qualify to be moved to a Medicare approved skilled nursing facility bed. This bed is often a "swing bed" in a hospital, although it may be in a separate facility or a part of a nursing facility. While you are a patient receiving daily skilled medical care, Medicare will pay 100% of the facility charges for the first 20 days and all but $101.50 a day for days 21-100. After 100 days, or if you stop receiving daily skilled medical care, Medicare will not provide coverage.

What home health care needs does Medicare Part A, cover? How do I qualify?

If you need part-time skilled care in your home, Medicare will pay for an unlimited number of home health visits. Medicare pays for home health visits only if all of the following conditions are met:

Covered services include part-time nursing care, therapy, and medical supplies and equipment.

How does the hospice care benefit work?

What are some of the items not covered by Medicare Part A?

It will never pay for personal convenience items such as telephones and televisions in your room; private duty nurses; or a private room, unless medically necessary.

What is covered by Medicare Part B medical insurance?

Part B medical insurance will help pay for:

How much will Medicare pay for items covered under Part B?

Medicare pays 80 percent of the "allowed charge." The approved charge is generally less than the doctor`s bill. You must pay a co-payment of 20 percent of the approved charge plus up to an additional 15% of the approved charge, that is, unless your doctor accepts assignment. For example, if your physician does not accept assignment and bills you $150 for a service for which the Medicare-approved charge is $100, Medicare will pay $80 of the approved charge and you must pay a $20 co-payment plus $15 of the amount over the approved charge of $100, for a total responsibility of $35.

What is assignment?

What services are not covered under Medicare Part B?

Even though the Medicare program has broad coverage, there are many services and supplies that are not paid for. These include custodial care; services not approved by Medicare; services for which the patient has no legal obligation to pay; services paid for by a governmental agency; personal comfort items; routine checkups; full-time home nursing care; hearing aids and eyeglasses and the examinations for prescribing or fitting them; prescription drugs or over-the-counter drugs except for some oral cancer drugs and immunosuppressives following a Medicare-covered transplant. Medicare also does not generally pay for chiropractic services, cosmetic surgery, dental care, private rooms, orthopedic shoes, or routine foot care.

What do I do if Medicare won`t pay?

When you disagree with a decision about your Medicare eligibility or claim, you have a right to a review. Appeals regarding eligibility should be made to the Social Security office. Appeals regarding claims should be made to the Medicare Fiscal Intermediary or Carrier. Call the appropriate office for the appeals procedure.

How do I appeal a Part A hospital insurance claim?

These are initially reviewed by the intermediary who made the decision. If you are still dissatisfied after the review and the amount Medicare refuses to pay is at least $100, you can ask for a formal hearing. Depending on the type of hearing and the disputed amount, you can eventually appeal to a federal court.

How do I appeal a Part B medical insurance claim?

If your claim is denied, you should first request a review by the carrier. If the claim is still denied and the amount in question is $100 or more, you can request a hearing before a carrier hearing officer. If you disagree with the hearing officer`s decision and the amount in question is $500 or more, you may request a hearing before an Administrative Law Judge. Cases involving $1,000 or more can eventually be appealed to a Federal Court.

Where can I get help in appealing a claim?

If you need assistance in appealing a claim that has been reduced or denied, you can contact an attorney or the Senior Law Project in your area. More information about Medicare coverage is available from your Area Agency on Aging or from Medicare (800) 432-3531. Counselors at the Senior Health Insurance Counseling for Kansas (SHICK) program may be available. These counselors have been trained to help with Medicare and other senior health insurance matters. For more information, call (800) 860-5260.

QMB (Qualified Medicare Beneficiary) Program

For people who cannot afford to buy a Medicare Supplemental Insurance policy, the Qualified Medicare Beneficiary program exists to "fill in the gaps" in Medicare. Resources could include checking and savings accounts, certificates of deposit, land, and the cash value of most life insurance. The home, car, personal items and keepsakes, and household furnishings are not counted as resources.

In 1993, a new version of the QMB program, the Low-income Medicare Beneficiary Program (LMB) began with higher eligibility limits and reduced benefits.

People can apply for QMB or LMB at any SRS office, or request the brochure, "Medicare Savings Programs." For more information about the QMB or LMB program, call the CMS toll-free telephone number, (800) 638-6833. When you become eligible for QMB or Medicaid, you can "freeze" your Medicare supplemental policy by calling your insurance company within 90 days of your eligibility for QMB or Medicaid. Your company will hold your policy for up to 24 months, during which you won`t pay any premium, and they won`t pay any claims. This allows you time to determine if QMB or Medicaid will do what you want without dropping your private Medicare Supplemental Insurance.

Medicaid Provides Health Care To Limited-Income Persons

Medicaid is a program designed by the federal government to pay the costs of some health care for individuals with limited income and resources.

Unlike Medicare, Medicaid provides health coverage to all eligible ages. It also pays for some important services, such as custodial nursing home care and prescriptions, that are a big concern for older persons. In Kansas, the Medicaid program is administered by the Department of Social & Rehabilitation Services (SRS) and Kansas Department on Aging (KDOA).

How do I qualify for Medicaid coverage?

Kansas provides three basic categories of eligibility for Medicaid for Kansas seniors. You may be eligible if any one of the following applies to you:

Where do I apply for Medicaid?

If you fit into one of the three categories, you can apply for Medicaid at your local SRS office.

What is the income limit for Medicaid?

Is all income received counted?

For the most part you will count all income you have received. However, some income is excluded, such as irregular, occasional or unpredictable monetary gifts; income and property tax rebates; in-kind income (such as free shelter) and most interest income.

Besides the income limit, what is the resource limit?

The limit in cash and cashable assets for one person is $2,000. For two persons, it is $3,000. Resources include checking and savings accounts, savings bonds, stock, jewelry, and other valuables.

What resources are not counted that I may keep?

You may keep household equipment and furnishings, property used solely as a home, one vehicle (plus one more if it is needed for employment, or to obtain medical care, or is specially equipped for a person with a disability), life insurance having a face value of no more than $1,500 per person, and resources designated for burial as approved by SRS.

Note: Any non-exempt resource that is transferred for less than fair market value can result in ineligibility for long-term care services for a penalty period.

What if I live in a long-term care facility?

Your income is figured on a monthly, rather than six-month basis. You are allowed to keep $50 per month as a personal needs allowance, and the remainder of your income is used to meet your cost of care.

If I am over the income limit, can I still be eligible?

You may be eligible for Medicaid under the spenddown provision. Eligibility is determined on a six-month basis. The difference between your actual income and the limit set by SRS is the spenddown amount. If medical expenses incurred during that time equal or exceed the spenddown amount, Medicaid will be available to you. This is like an insurance deductible.

If my spouse resides in a nursing home, must I spend assets before my spouse can qualify for Medicaid?

What services are covered by Medicaid?

They include physician`s services, prescription drugs, some ambulance services, lab tests, X-rays, home health services, inpatient or outpatient services, skilled intermediate nursing home care, eye and hearing examinations. Any services not covered by Medicaid must be paid by you.

How do I handle a Medicaid claim?

If you are eligible for both Medicare and Medicaid, the provider of the service must "take assignment" of Medicare benefits or Medicaid will not pay. The claim must first be submitted to Medicare for payment under that program.

Do all doctors accept Medicaid payment for services?

No. Providers of medical services cannot be forced to accept payment from Medicaid. Only those providers enrolled by Medicaid are certified to be part of this program.

What if my doctor does not accept Medicaid?

You have two options-change doctors or pay with your own funds. Also, if your doctor prescribes a drug that is not covered by Medicaid, ask if there is something else that can be prescribed that is covered-either an alternative drug or the same drug under a different trade mark name.

What if I am denied eligibility?

Private insurance can fill some gaps in Medicare coverage

Medicare provides a strong base of medical insurance, but it was never designed to pay all of your medical expenses. Basically, Part A pays the hospital charges after a deductible, for the first 60 days you are an inpatient in a hospital. Medicare Part B pays 80% of the Medicare-allowed charges for doctor`s fees and outpatient treatment at a hospital after a deductible of $100. A deductible is an amount you are responsible for before Medicare will pay. Co-insurance means that both you and Medicare are responsible for a portion of the bill. As a result, you will be responsible for the Part A and B deductibles and the co-insurance, as well as any amount over the Medicare allowance if your doctor does not accept the Medicare-allowed charge. These "gaps" become your responsibility. There are also a number of medical services that Medicare does not cover - like most prescription drugs, most dental services, and most optometry services.

What is available to help pay the amounts left after Medicare pays?

Do Medicare Supplemental policies cover non-Medicare expenses?

A few of the services not covered under Medicare are covered by some of the Medicare Supplemental policies. Limited benefits are available for foreign travel emergency, at-home recovery, prescription drug coverage and preventive medical care. This additional coverage adds to the prices of the policy, so before you buy this additional coverage be sure that the benefits you receive are greater than the additional cost of the coverage.

What about other health insurance policies, such as those that specify a specific illness?

Policies such as Cancer policies cover only specific costs of specific illnesses. Often Medicare will offer benefits for the same services. In some policies, the benefits are limited by waiting periods, diagnostic methods, and coverage only for the treatment of the specific illness and not for related illnesses. Before you purchase any specific illness insurance, be sure to understand all the limits of coverage. Special illness insurance should never be purchased instead of a comprehensive medical insurance program.

What are indemnity policies?

An indemnity is an agreement to pay so much per day under certain circumstances. Most indemnity policies are for hospital stays. These policies pay a set amount per day, week or month while you are hospitalized. A waiting period clause may require hospitalization for a set amount of days before payment begins and other limits may apply. Because of these limitations, a hospital indemnity policy should not be purchased instead of a comprehensive medical insurance program.

What are Medicare Health Maintenance Organizations (HMOs)?

Medicare HMOs are an alternative way for Medicare beneficiaries to receive their medical services. This alternative is currently available only in Johnson and Wyandotte counties and in specific zip codes in Leavenworth and Miami counties. Beneficiaries must select a physician subscribing to a certain plan and must use hospitals that are part of the plan`s "network". No supplemental insurance is required. Beneficiaries are still required to pay their Part B premium.

What about a retiree plan?

Some people can choose to continue their insurance from their employment to pay some of the gaps left from Medicare. Unlike Medicare Supplemental policies, this insurance is a benefit of employment; how the insurance works is determined by the company for whom you are employed. As a result, these policies may be much better for people on Medicare-such as the policies available to federal retirees-than what is available on a Medicare Supplemental Insurance policy. A careful comparison of retiree policies and Medicare Supplemental Insurance policies is the only way to make that decision. In most cases, if you refuse your employer`s retirement insurance you cannot get it back later; so that is an important decision.

However, people should not assume that health benefits from their employer`s insurance will be exactly the same once Medicare begins. Many policies have special rules on how it interacts with Medicare, and people should check these provisions carefully before making a final decision on how to fill the gaps in their Medicare coverage.

Things to Remember When Selecting a Medigap Policy -

Do I need to buy a Long-Term Care Policy?

Long-term care policies are not for everyone. If you cannot afford the premium, you should not be considering a long-term care policy. Before buying a long-term care policy, ask yourself:

Is there anywhere I can go for help making insurance decisions?

Helpful Insurance Booklets

The Kansas Insurance Department produces several publications on health insurance. These are available from the Consumer Assistance Division of the Kansas Insurance Department. Call them at (800) 432-2484. The booklets include: