Programs for elders

MEDICARE - the basic health insurance program for elders is Medicare. The Medicare program is complicated and it does not cover all of the services you may need. What follows is a summary of how Medicare works.

NTRODUCTION

Medicare is a federal health insurance program which provides health care benefits to those age 65 and over who are insured under the Social Security system. Medicare A covers hospital care. Medicare B covers physicians and other outpatient care. There are certain items and services that are excluded from coverage under both parts of the program.

Some of the services that are covered by Medicare require you to pay a portion of the costs because of deductible and coinsurance requirements. A "deductible" refers to a one-time payment which you must make before Medicare will begin to pay. "Coinsurance" refers to a portion that you or your secondary insurer (or Medigap insurer, e.g. Medex) must pay in addition to what Medicare pays.

MEDICARE A:

A. Inpatient Hospital Coverage:

Medicare will cover up to 90 days per "benefit period" for an inpatient hospitalization. A benefit period is defined as, "a period of consecutive days that begins with a hospitalization and ends when the patient has been discharged and has not been hospitalized again within 60 days".

You can have more than one benefit period per year. In addition to the 90 days, you also have an additional 60 "lifetime reserve days" which can be used all at once or can be spread out over several hospitalizations. You are responsible for paying the deductible for each "benefit period" which is $764.00 in 1998.

Example: Mr. Smith is hospitalized on April 8, 1998. He is released on April 12, 1998. He has to pay an inpatient hospital deductible of $764.00. He is hospitalized again on September 14, 1998. He has to pay another $764.00 because the second hospitalization is a new benefit period. If his second hospitalization had been within 60 days of his first hospitalization (within 60 days of April 12) he would not have had to pay another deductible for the second hospitalization.

In addition to this deductible, there is a coinsurance requirement for inpatient hospital stays of more than 60 days in the same benefit period up to the maximum 90 days. In 1998, the coinsurance charge for days 61-90 is $191.00 per day. The coinsurance payment for the 60 lifetime reserve days is $382.00 per day.

B. Skilled Nursing Facility Coverage:

Part A generally covers the same inpatient services provided in a participating skilled nursing facility as it does in a hospital. However, the services provided must be "skilled" nursing services and not merely "custodial". "Skilled services" are those that are provided by a physician, registered nurse, licensed practical nurse, physical therapist, or respiratory therapist. "Custodial services" are those that are provided in a long term care facility that do not require the skills of a trained professional. Some examples of custodial services would include feeding, helping a patient move from bed to chair, and help in going to the bathroom.

Skilled nursing facility care is only covered by Medicare if you have a previous hospital stay of at least three consecutive days within the 30 day period prior to the nursing home admission. There are also time limitations on nursing home care. Medicare covers 100 days per benefit period.

There are also coinsurance requirements for nursing home stays. In 1998, the coinsurance is $95.50 per day for days 21-100. There is no coinsurance payment for the first 20 days.

C. Hospice Coverage

Medicare covers hospice care for people who are terminally ill and who are diagnosed as having a life expectancy of six months or less. Most services provided by the hospice are covered, including the services of staff doctors.

To be eligible for hospice care, you must choose to receive hospice care instead of most other Medicare benefits. Hospice benefits include nursing care, various therapies, medical social services, homemaker-home health aide services, medical supplies and medical appliances, physicians' services, short-term inpatient care, respite care, and counselling. Medicare covers up to a maximum of 210 days of hospice care during the terminally ill person's lifetime.

D. Home Health Care

Part A covers services furnished by home health agencies to people who are essentially confined to their homes and need occasional skilled medical attention but who do not need inpatient care. Services covered are part-time or intermittent nursing care, physical, occupational and speech therapy, medical social services, part-time or intermittent services of a home health aide, medical supplies and durable medical equipment.

If you need five or more days per week of home health care you are entitled to 21 consecutive days of coverage. If you need fewer than five days per week of care, you are eligible to receive an unlimited number of days.

E. Respite Care

Part A does not cover any respite care.

MEDICARE B:

A. Physicians and Out-of-Pocket Expenses:

Part B coverage under Medicare depends upon the specific type of service needed and whether or not Medicare has decided that it is a covered service. The following services are covered:

1. Physician's services: surgery, consultation, home and office visits and visits by the doctor to a nursing home or hospital. Also covered are services and supplies used in connection with services provided by the physician. The term "Physician" includes M.D.'s, osteopaths, optometrists, podiatrists, chiropractors, and dentists. Podiatrists and dentists have very limited coverage. See the section on "exclusions from coverage" below.

2. Drugs and biologicals that cannot be self-administered (i.e., injections);

3. Outpatient hospital services including emergency room services, the services of hospital employees, hospital supplies, and specialized tests;

4. Physical and occupational therapy;

5. Speech pathology;

6. Diagnostic tests and therapies;

7. Surgical dressings;

8. Durable medical equipment;

9. Ambulance services when necessary;

10. Prosthetic devices;

11. Antigens, pneumococcal and hepatitis B vaccines, blood clotting factors, immunosuppressive drugs;

12. End-stage renal disease services and supplies;

13. Comprehensive outpatient rehabilitation facility services;

14. Outpatient surgery;

15. Pap smears performed at three year intervals; and

16. Home health services if not covered under Part A and if the patient has more than 100 home health visits per year.

B. Deductible and Coinsurance Payments:

There is an annual deductible of $100.00 per year and a coinsurance requirement of 20% of the Medicare approved charge.

Some services do not require a deductible or coinsurance payment. These include diagnostic laboratory tests, home dialysis services, transplant surgery services for kidney donors, pneumococcal vaccine and expenses connected with obtaining a required second opinion.

EXCLUSIONS FROM COVERAGE

The Medicare program does not cover the following under either Medicare A or B:

1. Routine check-ups

2. Glasses and examinations for glasses

3. Hearing aids and examinations for hearing aids

4. Routine foot care

5. Orthopedic shoes

6. Cosmetic surgery

7. Most dental work

8. Most immunizations

9. Private duty nurses

10. Custodial care

11. Personal comfort items

12. First three pints of blood per year

13. Homemaker services (except for hospice care)

14. Meals on wheels

MEDICARE PREMIUMS

For Medicare A, you do not have to pay a monthly premium. Medicare B, however, does require the payment of a monthly premium. In 2005, the monthly premium is $78.29 per month. This monthly premium is in addition to the deductible and coinsurance payments which were discussed above.

MASSACHUSETTS MEDICARE BALANCE BILLING LAW

In 1985, the Massachusetts legislature enacted a law which provides that a doctor who agrees to treat a Medicare beneficiary may not charge more than the Medicare approved reasonable charge for that service. The law is referred to as the Medicare Balance Billing Law.

Example: If a doctor charges you $75.00 for an office visit and Medicare determines $60.00 to be "Medicare approved amount", the doctor cannot "balance bill" you for the $15.00 difference. Since Medicare pays 80% of all approved charges, you or your secondary insurer will be responsible for paying the other 20%. In this example, Medicare would pay $48.00 and you would pay $12.00. The doctor cannot bill you for any more.

The Medicare Balance Billing Law is a state law. This is important to remember if you travel to other states and receive medical treatment there. Doctors outside of Massachusetts can "balance bill" you for the difference between their normal charge and what Medicare determines to be a reasonable charge.