Medicare

What is Medicare? Who is eligible for Medicare? What is Medicare Part A? What is Medicare Part B? What does Medicare cover? Does Medicare cover care for people with Alzheimer's? What if Medicare has denied coverage of medical services for a person with Alzheimer's? Does Medicare pay for prescription drugs? Will Medicare pay for the cost of long-term nursing care?

What is Medicare?

Medicare is a federally funded health insurance program that typically serves as the primary insurance for people over age 65, as well as people with certain disabilities or health conditions. In general, Medicare covers 80% of outpatient services (medical services that do not require hospitalizations) and all hospitalizations (minus a deductible).

CLICK HERE FOR IMPORTANT NEW INFORMATION ABOUT MEDICARE COVERAGE FOR PEOPLE WITH ALZHEIMER'S DISEASE.

Medicare coverage is divided into two general categories, Part A and Part B.

Part A - (Hospital insurance or Medicare Part A) helps pay for care in a hospital or skilled nursing facility, home healthcare and hospice care. Medicare Part A is premium-free for anyone automatically eligible for Medicare.

Part B - (Medical insurance or Medicare Part B) helps pay for doctors, outpatient hospital care and other medical services not requiring hospitalization. Medicare Part B can be purchased for a monthly premium.

A current guide to Medicare services, "Medicare & You 2003" can be obtained from the Center for Medicare and Medicaid Services (CMS). It contains a summary of Medicare benefits, rights and obligations and answers to the most frequently asked questions about Medicare. You can get a copy by calling the Social Security Administration at 1-800-772-1213, or you can download it online by visiting www.medicare.gov and following the links for "Medicare Plan Choices."

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Who is eligible for Medicare?

Medicare coverage is open to:

• People 65 years of age and older who are eligible for Social Security or Railroad Retirement benefits;
• People with specific disabilities under age 65 who are receiving Social Security Disability Income;
• People with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).

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What is Medicare Part A?

What it covers:
Care in hospitals as an inpatient (for services requiring admittance to a hospital), critical-access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities, hospice care, and some home healthcare. For more specifics on coverage, click here.

Cost:
Most people do not have to pay a monthly payment (called a premium) for Part A because either they or their spouse paid Medicare taxes while they were working.
If you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 or older, you still may be able to buy Part A (see below).

Enrolling:
Most people are automatically enrolled in Part A when they turn age 65. If you are not sure if you have Part A, look on your red, white and blue Medicare card. If you are covered, it will say "Hospital Part A" on the lower left corner of the card.

You can call your local Medicare office or the national toll-free number at 1-800-772-1213 for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office (this can be found in the blue government pages of your local phone book), or call 1-800-808-0772.

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What is Medicare Part B?

What it covers:
Doctors' services, outpatient hospital care, and some other medically necessary services that Part A does not cover, such as physical, occupational and speech therapists, and some home-healthcare services. For more specifics on coverage, click here.

Cost:
You pay the Medicare Part B premium of $50.00 per month. In some cases this amount may be higher if you did not choose Part B within seven months of becoming eligible at age 65. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it, except in special cases. You will have to pay this extra 10% for the rest of your life.

If you choose to have Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement or Civil Service Retirement payment. If you do not get any of the above payments, Medicare sends you a bill for your part B premium every three months. You should get your Medicare premium bill by the 10th of the month. If you do not get your bill by the 10th, call the Social Security Administration at 1-800-772-1213, or your local Social Security office (you can find the number in the blue government pages of your local phone book). If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

Enrolling
Enrolling in part B is your choice. You can sign up for Part B anytime during a seven-month period, which begins three months before you turn 65. Contact your local Social Security office, or call the Social Security Administration at 1-800-772-1213 to sign up.

For more information on Medicare, visit the official government site for Medicare information: www.medicare.gov.

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What does Medicare cover?

CLICK HERE FOR IMPORTANT NEW INFORMATION ABOUT MEDICARE COVERAGE FOR PEOPLE WITH ALZHEIMER'S DISEASE.

Part A Covers:

1. Hospital Stays: Semi-private room, meals, general nursing and other hospital services and supplies. This does not include private-duty nursing, a television or telephone in your room, or a private room, unless medically necessary. Inpatient mental healthcare coverage in a psychiatric facility is
limited to 190 days in a lifetime.

For each benefit period you pay:

• A total of $812 for a hospital stay of 1 to 60 days.
• $203 per day for days 61 to 90 of a hospital stay.
• $406 per day for days 91 to 150 of a hospital stay.
• All costs for each day beyond 150 days.

2. Skilled Nursing Facility (SNF) Care: Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (ONLY after a hospital stay of three days or more. There must be a need for skilled care to be eligible for coverage).

For each benefit period you pay:

• Nothing for the first 20 days.
• Up to $101.50 per day for days 21 to 100.
• All costs beyond the 100th day in the benefit period.

If you have questions about SNF care and conditions of coverage, call your Fiscal Intermediary, the company that pays Medicare Part A bills.

3. Home Healthcare: Part-time skilled nursing care, physical therapy, speech-language therapy, home-health aide services, durable medical
equipment (such as wheelchairs, hospital beds, oxygen and walkers) and supplies, and other services. Keep in mind: there must be a need for skilled nursing care, and it must follow a hospital stay of three days or more to qualify for coverage.

You pay:

• Nothing for home healthcare services.
• 20% of the approved amount for durable medical equipment, which must be prescribed by a doctor.

4. Companion Care Services: Medicare will cover this only if it is accompanied by a need for skilled nursing care after a hospital stay of three days or longer and is overseen by a skilled professional (such as a registered nurse). This is only covered for a designated amount of time following a hospital stay.

You pay:

• Nothing while receiving skilled care following a hospital visit.
• 100% if you wish to continue after the designated time period.

5. Assisted Living/Senior Housing/Adult Day Care/Long-term Nursing Home Care:
Medicare Part A or B does not, under any circumstances, cover any of the above.

You pay:

• 100% of the cost

NOTE: There are other options that can help pay for these types of long-term-care services. Click here for more information.

6. Dental Services:
Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. There are rare cases in which Medicare Part B will pay for certain dental services. In addition, there are some situations in which Medicare Part A will pay for certain dental services that require hospitalization.

7. Eye Exams:
Medicare DOES NOT pay for routine eye exams and eyeglasses. Medicare will help pay for one set of eyeglasses or contact lenses after cataract surgery.

8. Prescription Drugs:
As of August 2002, Medicare does not cover prescription drugs. However, in certain cases Medicare does cover some drugs, including immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs. Prescription drug benefits for Medicare enrollees are the subject of intense debate in the U.S. Congress, and changes to the Medicare policy are likely. Check back with www.alzinfo.org periodically for updates on this, or sign up for an email alert service to receive notices about updates.

PART B

1. Bone Mass Measurements:
Certain people with Medicare who are at risk for losing bone mass will qualify for coverage.

You pay:

• 20% of the Medicare-approved amount after the yearly Part B deductible is met.

2. Diabetes Monitoring:
Includes coverage for glucose monitors, test strips, lancets and self-management training. All people with Medicare who have diabetes (insulin users and non-users) are covered.

You pay:

• 20% of the Medicare-approved amount after the yearly Part B
  deductible is met.

3. Clinical Laboratory Service: Covers blood tests, urinalysis and more.

You pay:

• Nothing for services.

4. Companion Care: Part-time skilled care, home-health aide services, and durable medical equipment are covered by Medicare Part B only when these services follow a hospital stay of three days or more and the beneficiary is receiving medically necessary skilled care. Other medically necessary supplies and services may also be covered (see below).

You pay:

• Nothing for services.
• 20% of the approved amount for durable medical equipment.

5. Durable Medical Equipment:
Medicare Part B helps pay for durable medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that your doctor prescribes for use in your home. Other items covered by Medicare include:

• arm, leg, back and neck braces
• medical supplies such as ostomy pouches, surgical dressings, splints and casts
• breast prostheses following a mastectomy
• one pair of eyeglasses with an intraocular lens after cataract surgery

Medicare pays for different kinds of durable medical equipment in different ways. Some equipment must be rented, whereas other equipment must be purchased. For more information, contact your local Medicare office and ask them to refer you to the "Durable Medical Equipment Carrier" for your region.

For more information on Medicare, visit www.medicare.gov, the official U.S. Government site for Medicare information, or call 1-800-MEDICARE.

Source: Centers for Medicare and Medicaid Services (CMS) of U.S. Department of Health & Human Services

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Does Medicare cover care for people with Alzheimer's?

Thanks to a recent, important policy change, Medicare beneficiaries can no longer be denied coverage for mental health services, hospice care and home healthcare solely because they have Alzheimer's disease. Prior to this policy change, people with Alzheimer's were often automatically denied coverage for such services.

The services Medicare now covers include "reasonable and necessary" doctors' visits; physical, occupational or speech therapy; psychotherapy or behavioral management therapy by a mental health professional; and skilled home-care services (such as skilled nursing, speech or physical therapy).

The new policy, which was officially in place as of late 2001 but only became public in March 2002, reflects recent scientific evidence indicating that people with Alzheimer's can often benefit from mental health services and specialized types of therapy. Alzheimer's experts say the new rules will enable people with the disease to stay at home longer by providing access to services that help improve activities of daily living and help people with the disease maintain a better quality of life.

(Medicare still does not pay for prescription drugs for Alzheimer's, adult day care, room and board at assisted-living facilities, or custodial care in a nursing home, though it will pay for medically necessary skilled-care services at assisted-living facilities or nursing homes.)

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What if Medicare has denied coverage of medical services for a person with Alzheimer's?

Because of a recent Medicare policy change, some Medicare carriers may still be automatically denying coverage of medical services for people with Alzheimer's. If you or a loved one has been denied coverage of medical services by Medicare, you should contact your local Medicare office or your Medicare carrier, the company that reviews claims for the government in your area.

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Does Medicare pay for prescription drugs?

As of August 2002, Medicare does not cover prescription drugs. However, in certain cases Medicare does cover some drugs, including immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs.

Prescription drug benefits for Medicare enrollees are the subject of intense debate in the U.S. Congress, and changes to the Medicare policy are likely. Check back with www.ALZinfo.org periodically for updates on this, or sign up for an email alert service to receive notices about updates.

To learn about prescription drug benefit programs that you might be eligible for, please visit www.medicare.gov and follow the links for "Prescription Drug Assistance Programs." You can use the search tool at that site to find programs in your area.

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Will Medicare pay for the cost of long-term nursing care?

Medicare may pay for the cost of long-term nursing care, provided that the following conditions are met: (1) the individual must be hospitalized for at least three days; (2) the individual must be admitted to a skilled nursing facility within 30 days of the hospital discharge; and (3) the reason for admission to the skilled nursing facility must be the same reason/condition as the hospital stay. If the person is able to meet Medicare's stringent requirements, the first 20 days may be paid in full by Medicare, and days 21 to 100 are covered with a $101.50 per day co-payment. However, most patients do not qualify to receive benefits for the full 100 days. In other cases when these conditions are not met, the Medicare program typically pays for only 2% of long-term-care costs.