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Jacques Chambers, CLU, Benefits Consultant
In addition to providing health coverage for persons age 65 and over, the federal Medicare program also covers persons who are collecting disability benefits from Social Security Disability Insurance (SSDI). However, a person collecting SSDI benefits does not become eligible for Medicare until he/she has collected SSDI benefits for 24 months. With the five month waiting period for SSDI benefits to begin, Medicare doesn’t start until 29 months after the Onset Date of the disability.
Just like SSDI, if you didn’t pay into the Medicare system through Med/F.I.C.A. payroll deductions, you will not be eligible for Medicare coverage. Persons collecting SSI are not eligible for Medicare, although in most states, they will get Medicaid.
The actual benefits provided by traditional Medicare, also called fee-for-service Medicare, are, like most health insurance benefits, fairly complicated. You can obtain an excellent summary of Medicare benefits at: http://www.medicare.gov/
Traditional Medicare is in two parts:
Part A – Hospital: This portion covers hospitalization, skilled nursing facilities and some home health nursing.
Part B – Medical: This portion covers other medical charges, such as physicians, diagnostic testing, some preventive care and other medical charges.
Part A is automatic. Part B is considered voluntary and once coverage starts, $58.70 will be deducted from each monthly Social Security payment to pay for it.
The Medicare card will arrive in the mail about two months before the eligibility date. Because Part B is considered such an important part of the coverage, you will be automatically enrolled in it. If you decide you do not need the Part B coverage, you should return your Medicare card and “disenroll” from the Part B coverage. The instructions come with the card.
Be careful before dropping Part B, as there are penalties if you later find that you need to obtain the coverage. Just because you have other coverage does not mean that you don’t need Medicare Part B. Many health plans reduce their benefits by what Medicare Part A and Part B would pay, whether or not you are actually enrolled in Part B. Before refusing Part B, talk to a knowledgeable person about your specific situation.
Even with both parts of Medicare, not all medical bills will be covered or paid. While Part A covers most hospital charges, there is an $840 (in 2003) hospital deductible. Medical charges under Part B are covered only up to 80% of physician’s charges and other covered medical expenses after a $100 annual deductible.
Medicare, with few exceptions, does not cover prescription drug charges, although it does cover chemotherapy whether in-patient or out-patient. It limits or pays only a portion of many other medical bills. As good as Medicare is, additional coverage for items that Medicare does not cover can be important.
There are several ways to augment the traditional Medicare coverage including some special programs for persons with limited income. Some of the ways to get assistance with what Medicare does not cover includes:
Trading Traditional Medicare for a Different Medicare Product. Private insurance companies and HMOs offer Medicare plans that you may join as a replacement of traditional Medicare. When you join one of these plans, your regular Medicare stops and the federal government pays the insurance company to provide for your care. In some areas of the country, the insurance company may charge the member a premium as well, but it is usually low.
While the law permits many different types of these “Medicare+Choice” plans, the most common type available at present is the Medicare Health Maintenance Organization (HMO). By law, every Medicare HMO must cover all that traditional Medicare covers, but many HMOs will offer additional benefits such as eyeglass coverage, hearing aids, some prescription drug coverage and other incentives to join their plan.
At the present time, virtually anyone who is enrolled in both Parts A & B of Medicare may switch their coverage to one of the Medicare+Choice products or back to traditional Medicare without any limitations. In the near future you will be able to switch from one plan to another only once in a twelve month period, but the implementation date for that change has been moved back.
Other Health Insurance Plans. If you have other health insurance, either an individual policy or are able to continue coverage under your employer’s policy, it will coordinate with your Medicare coverage to pay for what Medicare does not cover. In many ways this is the best possible supplement to traditional Medicare since these plans usually provide broad coverage with unlimited prescription coverage. Between the insurance plan and Medicare, it is possible that you will not have to make any payment for medical care at all.
The primary drawback to these plans is that the premiums are not discounted in cost even though Medicare may pay most of the bill, and health insurance premiums can be expensive. Also, unless you are already covered under another health insurance plan, it will be practically impossible to obtain private insurance coverage once you become eligible for Medicare.
Medicare Supplement (Medigap) Plans. Insurance companies offer plans that are specifically designed to supplement traditional Medicare. There are ten different Medigap plan designs. They cover things such as the deductibles, 20% of doctor’s fees, coverage when out of the country, and other benefits. Three of the plans provide a limited amount of prescription drug coverage as well.
Medicare requires that Medigap plans be offered during an open enrollment period when a person first gets Medicare at age 65. Unfortunately, there is no provision from the federal government for a similar open enrollment for persons under age 65, so, in many states, these plans are not available to persons under age 65. If they are, the insurance company requires evidence of good health. That effectively blocks coverage since you can’t get Medicare under age 65 unless you are disabled, which means “uninsurable” to an insurance company.
Some states, however, California and New York being two of the larger ones, have enacted legislation that requires an open enrollment period for all persons getting Medicare, even those under age 65. Call your state’s Department of Insurance to see what is available in your state.
Medicaid (called Medi-Cal, TennCare and other names in different states). The health program available in each state for the medically needy provides an excellent supplement to Medicare if you can meet the financial limitations to qualify. In addition to paying what Medicare doesn’t cover, including prescription drugs, Medicaid will also pay the Part B Medicare premium for you.
Medicaid usually is automatic if you get any payment at all from SSI. If not, you may still be eligible for it, but you must apply for it directly. To enroll in Medicaid, contact your state or county Department of Social Services. Since these offices are the same offices that handle food stamps, general relief and other needs-based programs, they are often crowded with long waits, but if you can get Medicaid to cover what Medicare does not, it may be worth the inconvenience.
Other federal assistance. The federal government makes available several other programs to assist persons whose income is low, but not low enough to qualify for Medicaid directly. Even though these are federal programs, application must be made at your local Medicaid office.
To qualify for these programs, assets need to be less than $4,000 for a single individual and $6,000 for a couple. The maximum income to qualify varies by program. The primary programs are:
Qualified Medicare Beneficiary (QMB) – Maximum income: $748 per month for a single person. QMB benefits include paying the Part B Medicare premium plus the Medicare deductibles and 20% coinsurance.
Specified Low Income Beneficiary (SLMB) – Maximum income: $898 per month for a single person. SLMB pays the Part B Medicare premium.
Qualified Individual 1 (QI1) – Maximum income: $1,010 per month for a single person. QI1 pays the Part B medical premium.
If your income is close to any of the above figures, you should apply as certain types of income may be disregarded for eligibility purposes.
Medicare is a fairly broad health insurance plan. Most hospitals are happy to serve Medicare patients. Although there have been articles lately about doctors dropping out of Medicare coverage, a large number still participate. It is possible to find participating doctors experienced in HCV in most parts of the country.
Like most other health insurance plans, however, Medicare has some gaps that can have a major effect on your finances, so take advantage of whatever programs you may qualify for to help pay your medical expenses.
Confused about applying for disability? Click here
[Jacques Chambers, CLU, and his company, Chambers Benefits Consulting, have over 35 years of experience in health, life and disability insurance and Social Security disability benefits. For the past twelve years, he has been assisting people with their rights, problems, and other issues concerning benefits and disability. He can be reached at jacques@helpwithbenefits.com or through his website at: http://www.helpwithbenefits.com.]
Copyright March 2003 – Hepatitis C Support Project - All Rights Reserved. Permission to reprint is granted and encouraged with credit to the Hepatitis C Support Project.
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