Eligible for Medicare?
Generally, you are eligible for Medicare if you or your spouse
worked for at least 10 years in Medicare-covered employment and you are 65 years old and a
citizen or permanent resident of the United States. You might also qualify for
coverage if you are a younger person with a disability or with chronic kidney disease.
Here are some simple guidelines. You can get Part A at age 65
without having to pay premiums if:
Enrollment in Medicare is handled in two ways: either you are enrolled automatically or you have to apply. Here's how it works.
If you are not yet 65 and already getting Social Security or Railroad Retirement benefits, you do not have to apply for Medicare. You are enrolled automatically in both Part A and Part B and your Medicare card is mailed to you about 3 months before your 65th birthday. If you do not want Part B, follow the instructions that come with the card.
If you are disabled, you will be automatically enrolled in both Part A and Part B of Medicare beginning in your 25th month of disability. Your card will be mailed to you about 3 months before you are entitled to Medicare.
Applying for Medicare
You need to apply for Medicare if you are not receiving Social Security or Railroad Retirement Benefits three months before you turn 65, or if you require regular dialysis or kidney transplant. That's the beginning of your 7-month initial enrollment period. By applying early, you'll avoid a possible delay in the start of your Part B coverage. You apply by contacting any Social Security Administration office or, if you or your spouse worked for the railroad, the Railroad Retirement Board.
If you do not enroll during this 7-month period, you'll have to wait to enroll until the next general enrollment period. General enrollment periods are held January 1 to March 31 of each year, and Part B coverage starts the following July.
Don't put off enrolling. If you wait 12 or more months to sign up, your premiums generally will be higher. Part B premiums go up 10 percent for each 12 months that you could have enrolled but did not. The increase in the Part A premium (if you have to pay a premium) is 10 percent no matter how late you enroll for coverage.
Under certain circumstances, however, you can delay your Part B enrollment without having to pay higher premiums. If you are age 65 or over and have group health insurance based on your own or your spouse's current employment, or if you are disabled and have group health insurance based on your current employment or the current employment of any family member, you have a choice:
If you enroll in Part B while covered by an employer plan or during the first full month when not covered by that plan, your coverage begins the first day of the month you enroll. You also have the option of delaying coverage until the first day of the following 3 months. If you enroll during any of the 7 remaining months of the special enrollment period, your coverage begins the month after you enroll.
If you do not enroll by the end of the 8-month period, you'll have to wait until the next general enrollment period, which begins January 1 of the next year.
Even if you continue to work after you turn 65, you should sign up for Part A of Medicare. Part A may help pay some of the costs not covered by the employer plan. It may not, however, be advisable to sign up for Part B if you have health insurance through your employer. You would have to pay the monthly Part B premium, and the Part B benefits may be of limited value to you as long as the employer plan was the primary payer of your medical bills. Moreover, you would trigger your 6-month Medigap open enrollment period (see Medigap Insurance).
Assistance for Low-Income Beneficiaries
If you have a low income and limited resources, your State may pay your Medicare costs, including premiums, deductibles, and coinsurance. To qualify:
If your income is just above the poverty guidelines, you may qualify for help with paying your Part B premiums. If you think you qualify, contact your state or local welfare, social service, or Medicaid agency. The contact number is available on the Internet at www.medicare.gov. Ask about the Qualified Medicare Beneficiary (QMB) program, the Medicare Buy-In program, the Specified Low-Income Medicare Beneficiary (SLMB) program, or the Qualifying Individual (QI) program.
If you have young children in your care, you also should ask about your State's Child Health Program to help pay their health care costs.
Medicare Covered Services
Hospital Insurance (Part A)
Medicare hospital insurance helps pay for necessary medical care and services furnished by Medicare-certified hospitals, skilled nursing facilities, home health agencies, and hospices.
The number of days that Medicare covers care in hospitals and skilled nursing facilities is measured in benefit periods. A benefit period begins on the first day you receive services as a patient in a hospital or skilled nursing facility and ends after you have been out of the hospital or skilled nursing facility and have not received skilled care in any other facility for 60 days in a row. There is no limit to the number of benefit periods you can have.
Inpatient Hospital Care
Medicare Part A helps pay for up to 90 days of inpatient hospital care in each benefit period. Covered services include your semi-private room and meals, general nursing services, operating and recovery room costs, intensive care, drugs, laboratory tests, X-rays, and all other necessary medical services and supplies.
Skilled Nursing Facility Care
You may need inpatient skilled nursing or rehabilitation services after a hospital stay. If you meet certain conditions, Part A helps pay for up to 100 days in a participating skilled nursing facility in each benefit period. Medicare pays all approved charges for the first 20 days; you pay a coinsurance amount for days 21 through 100. Covered services include your semi-private room and meals, skilled nursing services, rehabilitation services, drugs, and medical supplies.
Home Health Care
If you meet certain conditions, Medicare pays the full approved cost of covered home health care services. This includes part-time or intermittent skilled nursing services prescribed by a physician for treatment or rehabilitation of homebound patients. The only amount you pay for home health care is a 20 percent coinsurance charge for medical equipment such as a wheelchair or walker.
Medicare helps pay for hospice care for terminally ill beneficiaries who select the hospice care benefit. There are no deductibles, but you pay limited costs for drugs and inpatient respite care.
Medical Insurance (Part B)
Medicare Part B helps pay for doctor's services, outpatient hospital services (including emergency room visits), ambulance transportation, diagnostic tests, laboratory services, some preventive care like mammography and Pap smear screening, outpatient therapy services, durable medical equipment and supplies, and a variety of other health services. Part B also pays for home health care services for which Part A does not pay.
Medicare Part B pays 80 percent of approved charges for most covered services. You are responsible for paying a $100 deductible per calendar year and the remaining 20 percent of the Medicare approved charge. You will have to pay limited additional charges if the doctor who cares for you does not accept assignment. This means the doctor does not agree to accept the Medicare approved charge for services.
Services Medicare Does Not Cover
Medicare Part A does not pay for convenience items such as telephones and televisions provided by hospitals or skilled nursing facilities, private rooms (unless medically necessary), or private duty nurses.
The only type of nursing home care Medicare pays for is skilled nursing facility care for rehabilitation, such as recovery time after a hospital discharge. Medicare does not pay if you need only custodial services (help with daily living activities like bathing, eating or getting dressed).
Medicare Part B usually does not pay for most prescription drugs, routine physical examinations, or services not related to treatment of illness or injury. Part B does not pay for dental care or dentures, cosmetic surgery, routine foot care, hearing aids, eye examinations, or eyeglasses.
Except for certain limited cases in Canada and Mexico, Medicare does not pay for treatment outside the United States.
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