Medicare Medicare and Your Medicare Rightsand Your Medicare Rights

By Sylvia GaddisFlorida Medical Quality Assurance, Inc.

Medicare is a health insurance program for: People age 65 or older Some people under 65 with disabilities

Usually required to be eligible for Social Security Disability for at least 2 years

People with End-Stage Renal Disease (ESRD) (permanent kidney failure)

People with Lou Gehrig’s Disease (ALS)

MEDICARE HEALTH INSURANCE

SOCIAL SECURITY ACTNAME OF BENEFICIARY

JOHN D. DOE

MEDICARE CLAIM NUMBER SEX

123-45-6789A MALE

IS ENTITLED TO EFFECTIVE DATE

HOSPITAL INSURANCE (PART A) 1/1/95MEDICAL INSURANCE (PART B)

SIGN HERE John D. Doe

BA““Hospital Insurance”Hospital Insurance” “Doctor Insurance”

Part A is premium free for most people Part A Hospital Deductible

$812 per benefit period

Part A Hospital Co-insurance Days 1-59 No Co-insurance Days 61-90 $203 per day Days 91-150 $406 per day

Part A helps pay for things like: Hospital Stays Nursing Home Care (Very Limited) Home Health Care Hospice Care

Part A “Benefit Period”You pay only one deductible for each benefit period

Starts the day admitted

Ends when no care received for 60 days

No limit to the number of benefit periods

Part A Nursing Home CareFor Each Benefit Period:Covered in full for 20 days

(after hospital admission only)

Co-insurance• You pay $99 per day for days 21-100• You pay all costs after 100 days

Part B Premium $54 per month

Part B Deductible $100 each year

Part B Coinsurance 20% of approved amount for most services 20% of outpatient charges

Part B helps pay for things like: Doctors’ Visits Outpatient Surgery Preventive Health Care Outpatient Tests Medical Equipment Used at Home Ambulance Services

Medigap Covers Payment ‘Gaps’ in Original Medicare Standardized Plans ‘A’ through ‘J’ Sold by Private Insurance Companies May Help Lower Out-of-Pocket Costs

Covered ServicesAmbulanceArtificial eyesArtificial limbsBraces - arm, leg, back, and neckChiropractic services (limited)Emergency careEyeglasses (one pair after cataract surgery))

Covered ServicesImmunosuppressive drug therapyKidney dialysisMacular degeneration treatmentMedical nutrition therapyMedical suppliesProsthetic devicesTransplants

Therapy Coverage of Alzheimer’s Disease PatientsStatement of Tom Scully, Administrator

Centers for Medicare & Medicaid Services

“Advances in medical science are helping physicians diagnose Alzheimer’s Disease at its earliest stages. Depending on a beneficiary’s medical condition, the Centers for Medicare & Medicaid Services believes that certain specific therapies can be helpful in slowing a beneficiary’s decline due to this terrible illness.”

Therapy Coverage of Alzheimer’s Disease PatientsStatement of Tom Scully, Administrator

Centers for Medicare & Medicaid Services

Medicare provides payment for the following:•specific speech therapy•occupational therapy •rehabilitation therapy•neuro-diagnostic testing•medication management•psychological therapy

The memorandum from Mr. Scully is available at http://hcfa.gov/pubforms/transmit/AB01135.pdf.

Preventive HealthcareDiabetes MonitoringNutritional Therapy

For those with Diabetes/Kidney DiseaseGlaucoma ScreeningFlu (influenza) shotPneumonia VaccinationHepatitis B Vaccination

Preventive HealthcareColon Cancer ScreeningProstate Cancer ScreeningMammogram ScreeningBone Mass MeasurementsPap Tests/Pelvic Exams

Non-covered ServicesAcupunctureDental care and denturesCosmetic SurgeryCustodial Care at home or in Nursing HomeHealth care while traveling outside the USAHearing aids and hearing examsOrthopedic shoes

Non-covered ServicesOutpatient prescription drugs (with a few exceptions)Routine foot care (with only a few exceptions)Routine eye care and most eyeglassesRoutine or yearly physical examsScreening tests

except those listed as covered preventive services

Shots (vaccinations) except those listed as covered preventive services

Medicare Rights If you have Medicare, you have certain

guaranteed rights and protections.

You have these rights whether you have the Original Medicare Plan, a Medigap policy, a Medicare HMO.

Medicare Rights Respect Protection Against Discrimination Easy to Understand Information Emergency care Treatment Choices Privacy of Personal Information Privacy of Health Information Culturally Competent Services

Medicare Rights Appeals

Billing, Payment, or Services

Grievances

Quality of Care Issues

Medicare RightsAppeal a Hospital Discharge if you feel you

are too sick to leave

You do NOT have to leave the hospital You do NOT have to pay for the extra days you are

in the hospital while we look at your medical record.

Thank You!

If you have questions,call 1-800-MEDICARE