Medicare / Medicaid

 

Medicare

Medicare is a government funded health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure. An additional requirement is that you must have entered the United States and lawfully lived here for five years. Medicare’s scope of coverage is generally divided into two parts, Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

Medicare Part A

Medicare Part A will help to pay for inpatient care that you receive in a hospital, nursing home, hospice, or at home. There are usually no monthly premiums because either you or your spouse have paid Medicare taxes while working in the United States. If you do not qualify for premium-free Part A, you may still be able to enroll, and pay a premium. In 2011, you pay up to $450 each month if you do not qualify for premium-free Medicare Part A. To obtain information on enrolling you can call:

1-800-MEDICARE (1-800-633-4227)

Medicare Part A will specifically cover inpatient care in hospitals, inpatient care in a SNF, hospice care services, home health care services, and inpatient care in religious nonmedical health care institutions.

Medicare Part B

Medicare Part B will help you to pay for medically-necessary doctors’ services, durable medical equipment, and other outpatient care such as physical therapy. It will also help to pay for certain preventive services in order to keep you healthy and keep certain illnesses from getting worse. There usually is a standard monthly premium for this coverage which changes every year. For 2011, the premium rates are as follows:


File Individual Tax Return File Joint Tax Return You Pay
$85,000 or less $170,000 or less $115.40
Above $85,000 up to $107,000 Above $170,000 up to $214,000 $161.50
Above $107,000 up to $160,000 Above $214,000 up to $320,000 $230.70
Above $160,000 up to $214,000 Above $320,000 up to 428,000 $299.90
Above $214,000 Above $428,000 $369.10

These numbers will be based on your yearly income in 2009. If you have any questions about your Part B premium, you can call Social Security at 1-800-772-1213.

Because Part B covers such a wide range of services, it may be helpful to have a list of covered services. Below is a comprehensive list of services that are covered. Please note that the Part B deductible may apply and you may also have to pay 20% of the Medicare-approved amount upon being treated. For a more detailed explanation of the costs of these services, you can view the Medicare & You Handbook online at:

www.medicare.gov/Publications/Pubs/pdf/10050.pdf

Part B Covered Services:


Abdominal Aortic Aneurysm Screening Home Health Services
Ambulance Services Kidney Dialysis Services and Supplies
Ambulatory Surgical Center Visits Kidney Disease Education Services
Blood Services Mammograms (screening)
Bone Mass Measurement (Bone Density) Medical Nutrition Therapy Services
Cardiac Rehabilitation Mental Health Care (outpatient)
Cardiovascular Screenings Non-doctor Services
Chiropractic Services Occupational Therapy
Clinical Laboratory Services Outpatient Medical and Surgical Services and Supplies
Clinical Research Studies Pap Tests and Pelvic Exams (includes clinical breast exam)
Colorectal Cancer Screenings Physical Exams
Defibrillator (Implantable Automatic) Physical Therapy
Diabetes Screenings Pneumococcal Shot
Diabetes Self-Management Training Prescription Drugs (limited)
Diabetes Supplies Prostate Cancer Screenings
Doctor Services Prosthetic/Orthotic Items
Durable Medical Equipment (like walkers) Pulmonary Rehabilitation
EKG Screening Rural Health Clinic Services
Emergency Department Services Second Surgical Opinions
Eyeglasses (limited) Smoking Cessation (counseling to stop smoking)
Federally-Qualified Health Center Services Speech-Language Pathology Services
Flu Shots Surgical Dressing Services
Foot Exams and Treatment Telehealth
Glaucoma Tests Tests (other than lab tests)
Hearing and Balance Exams Transplants and Immunosuppressive Drugs
Hepatitis B Shots Travel (health care needed when traveling outside the United States)
HIV Screening Urgently-Needed Care

Note: In Pennsylvania you need to use specific suppliers for Medicare
to pay for the following items:

  • Oxygen supplies and equipment
  • Standard power wheelchair, scooter, and related accessories
  • Certain complex rehabilitative power wheelchairs and related accessories
  • Mail-order diabetes supplies
  • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RAD) and related supplies and accessories
  • Walkers and related accessories

Go to www.medicare.gov/supplier to find a list of Medicare-approved suppliers.


What is NOT covered by Part A and Part B

Medicare is not going to cover everything that you may need to ensure you are taking care of your health. If something is not covered you will have to pay for it yourself or you may have supplemental health insurance that may cover it. Some items that Medicare will not cover include long-term care, routine dental care, dentures, cosmetic surgery, acupuncture, hearing aids, and exams for fitting hearing aids. To find out if Medicare covers a service you need, you can visit: www.medicare.gov/coverage or call: 1-800-633-4227

What is Medigap?

Medigap is a supplemental insurance policy that you can obtain through private insurance companies to help you pay for your health care costs that are not covered by Medicare. All of the plans offer the same basic benefits but some will offer additional benefits. Make sure you choose a plan to fit your needs if this is something that you are considering. You also want to shop around because private insurance companies may charge different premiums for the exact same Medigap coverage. For more information about Medigap policies please visit: http://go.usa.gov/lot to view a comprehensive booklet that will help you to choose a plan to fit your needs.

You may also call Pennsylvania’s State Health Insurance Assistance Program at:

1-800-692-7462

General information regarding coverage and factors to be considered

The Centers for Medicare and Medicaid Services publishes a Medicare & You Handbook each year. The PDF version of this handbook can be found by going to

www.medicare.gov/Publications/Pubs/pdf/10050.pdf

This is the official United States government Medicare handbook that contains important information about costs, coverage, prescription drug plans, and your Medicare rights. This handbook will also explain how and when to sign up for Medicare coverage under Part A and Part B. If you are 65 and disabled, you will automatically get Part A and Part B after you get disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board (if applicable).

Contact information for local resources

Each state has a health insurance assistance program and you can call them for free health insurance counseling and personalized help in understanding your coverage. The number for the State Medical Assistance Office in Pennsylvania is: 1-800-692-7462

Other helpful contacts for Pennsylvania residents:

Organization name Agency name Can answer questions about Contact information
Carrier Highmark Medicare Services Part B bills and services 1-800-633-4227
Durable Medical Equipment Medicare Administrative Contractor National Heritage Insurance Company Bills for durable medical equipment and a list of approved suppliers of this equipment 1-800-633-4227
Fiscal Intermediary Highmark Medicare Services Part A bills and services, hospital care, skilled nursing care, and fraud 1-800-633-4227
Social Security Administration Social Security Administration Changing my address, Medicare Part A or Part B, lost Medicare card, and Social Security benefits 1-800-772-1213

Medicaid

The Pennsylvania Medicaid Policy Center provides an abundant amount of information regarding Medicaid in Pennsylvania and also contains links to many frequently asked questions. You can view this website by going to www.pamedicaid.pitt.edu.

Medicaid is a welfare program that finances health services to low-income individuals and families. Medicaid provides health insurance coverage, offers long-term care assistance to people over the age of 65 with disabilities, covers gaps in the Medicare program, and funds institutions that serve low-income patients with special needs. To find out if you may be eligible and to apply for benefits you can go to the Pennsylvania Department of Public Welfare’s website at www.dpw.state.pa.us.

Additionally, the Office of Medical Assistance Programs website provides information on medical assistance programs in Pennsylvania. To view their website please visit www.dpw.state.pa.us/dpworganization/
officeofmedicalassistanceprograms/index.htm
.

Residents of Pennsylvania can seek assistance and a range of services also by contacting staff members at their county assistance offices. The following website provides contact information for each county in Pennsylvania:

http://www.dpw.state.pa.us/findfacilsandlocs/
countyassistanceofficecontactinformation/index.htm
.


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