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 2014, you could pay up to $426 each month if you do not qualify for premium-free Medicare Part A. It should also be noted that if you do not enroll when you first become eligible, your monthly premium may go up 10% and you will have to pay for the higher premium for twice the number of years you could have had Part A but did not sign up.
There are some people who will become automatically enrolled in Medicare Part A & B. For example, if you are receiving Social Security or Railroad Retirement Board benefits, if you are under sixty-five (65) years of age and have a disability, if you have ALS (a.k.a. – Lou Gehrig’s disease), or you live in Puerto Rico and get benefits from Social Security or the Railroad Retirement Board, you may qualify automatically and will receive your Medicare card in the mail three (3) months prior to your 65th birthday or your 25th month of disability.  If you do not qualify for Medicare automatically, you will need to sign up. To obtain information on enrolling please visit the following webpage or contact Social Security via telephone at the following number:

http://www.socialsecurity.gov/medicareonly/
1-800-772-1213

You can also visit your local Social Security office to enroll. Finally, if you ever worked for a railroad, please contact the Railroad Retirement Board for enrollment information at 1-877-772-5772.

Medicare Part A will specifically cover inpatient care in hospitals, inpatient care in a skilled nursing facility (SNF), nursing home care (as long as custodial care isn’t the only care you need), hospice care services, and home health care services. If you have questions about your coverage, discuss Medicare coverage of specific services or supplies with your physician. You can also visit Medicare’s website or call Medicare directly for coverage related questions at:

http://www.medicare.gov/coverage/your-medicare-coverage.html

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

Medicare Part B

Medicare Part B will help you pay for medically-necessary doctors’ services, durable medical equipment, clinical research, ambulance services, mental health treatment, outpatient prescription drugs and other outpatient care such as physical therapy. It will also help pay for certain preventive services in order to keep you healthy and keep certain illnesses from getting worse. There is usually a standard monthly premium for this coverage, which changes every year and is based on your income. For 2014, the premium rates are as follows:

File Individual Tax Return

File Joint Tax Return

File Married & Separate Tax Return

You Pay

$85,000 or less

$170,000 or less

$85,000 or less

$104.90

Above $85,000 up to $107,000

Above $170,000 up to $214,000

Not applicable

$146.90

Above $107,000 up to $160,000

Above $214,000 up to $320,000

Not Applicable

$209.80

Above $160,000 up to $214,000

Above $320,000 up to $428,000

Above $85,000 and up to $129,000

$272.70

Above $214,000

Above $428,000

Above $129,000

$335.70

These numbers will be based on your yearly income in 2012. If you have any questions about your Part B premium, you can telephone 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:
http://www.medicare.gov/Pubs/pdf/10050.pdf

Part B Covered Services:


Abdominal Aortic Aneurysm Screening

Home Health Services

Alcohol Misuse Screening and Counseling

Kidney Dialysis Services and Supplies

Ambulance Services

Kidney Disease Education Services

Ambulatory Surgical Center Visits

Mammograms (screening)

Blood Services

Medical Nutrition Therapy Services

Bone Mass Measurement (Bone Density)

Mental Health Care (outpatient)

Cardiac Rehabilitation

Obesity Screening and Counseling

 

Occupational Therapy

Cardiovascular Disease Screenings and Behavioral Therapy

Outpatient Hospital Services

Chemotherapy

Outpatient Medical and Surgical Services and Supplies

Pap Tests and Pelvic Exams (includes clinical breast exam)

Clinical Laboratory Services

Physical Exams

Clinical Research Studies

Physical Therapy

 

Pneumococcal Shot

Colorectal Cancer Screenings

Prescription Drugs (limited)

Cervical and Vaginal Cancer Screening

Prostate Cancer Screenings

Defibrillator (Implantable Automatic)

Prosthetic/Orthotic Items

Diabetes Screenings

Pulmonary Rehabilitation

Diabetes Self-Management Training

Rural Health Clinic Services

Diabetes Supplies

Second Surgical Opinions

Doctor Services

Sexually Transmitted Infections Screening and Counseling

Durable Medical Equipment (like walkers)

  1. Note: In Pennsylvania, and all areas of the country, you need to use a Medicare-approved supplier for Medicare to pay for durable medical equipment.
  2. Go to www.medicare.gov/supplier to find a list of Medicare-approved suppliers in your area. 

Speech-Language Pathology Services 

EKG (Electrocardiogram) Screening

Surgical Dressing Services  

Emergency Department Services

Smoking Cessation (counseling to stop smoking)

Eyeglasses (limited)

Telehealth

Federally-Qualified Health Center Services

Tests (other than lab tests)

Flu Shots

Transplants and Immunosuppressive Drugs

Foot Exams and Treatment

Travel (health care needed when traveling outside the United States)

Glaucoma Tests

Urgently-Needed Care

Hearing and Balance Exams

 

Hepatitis B Shots  

 

HIV Screening

 

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 (custodial care), routine dental care, dentures, cosmetic surgery, acupuncture, hearing aids and exams for fitting hearing aids, and routine foot care. To find out if Medicare covers a service you need, you can visit:
http://www.medicare.gov/coverage/your-medicare-coverage.html
Or telephone: 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 telephone 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.
                       

Contact Information for Local Resources

Each state has a health insurance assistance program and you can telephone 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

Medicaid

Medicaid is a welfare program that finances health services to low-income individuals and families. Medicaid is jointly funded by the State and the Federal Government. It generally covers children, the elderly, blind, and/or disabled individuals who are eligible for assisted income. Pennsylvania provides Medicaid eligibility to people who are eligible for Supplemental Security Income (SSI) benefits. 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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