Medicare

Medicare is health insurance provided by the federal government. You qualify for Medicare coverage if you are 65 or older and eligible for Social Security benefits, if you are disabled (regardless of age) and have collected Social Security benefits for 2 years, or if you have been diagnosed with permanent kidney failure or Amyotrophic Lateral Sclerosis (ALS or Lous Gehrig's Disease) regardless of your age. Medicare will not refuse you coverage or charge you more because of where you live, your age, or how sick you are.

There are several parts to Medicare, as well as options for arranging one's Medicare benefits. The program has expanded significantly since its inception in 1965, and Medicare beneficiaries can be confused by its many rules and limitations for good reason. The addition of Medicare Prescription Drug Coverage, known as Part D, added new options and potential combinations of benefits, outlined below. Anyone soon to become eligible for Medicare or interested in maximizing their rights and responsibilities as a Medicare beneficiary at any time would be wise to carefully review their needs and options in light of the costs and consequences of each.

Medicare Part A covers care you receive in a hospital, skilled nursing facility, home health agency, or other facility. For most people who qualify for Medicare, there is no premium for Part A. You will, however, have to pay a deductible. In 2006, the deductible was $952 per benefit period. (A benefit period starts the day you go to the hospital or skilled nursing facility and ends when you have not received hospital or skilled nursing care for 60 days in a row.) Also, for longer stays in a hospital or nursing home, you will have to pay coinsurance. Note: Medicare Part A covers chemotherapy drugs and the costs of administering them when given in hospital outpatient departments, chemotherapy clinics, or doctors’ offices.

Medicare Part B covers 80 percent of approved medical expenses, such as doctors’ charges, lab fees, durable medical equipment, ambulance services, and certain other supplies. In 2006, the monthly premium for Part B was $88.50, which is deducted directly from your Social Security check. In addition to your 20 percent coinsurance, there is also a $124 annual deductible for covered services.

Physicians participating in Medicare “accept assignment” on all Medicare beneficiaries. That means they may charge only what Medicare approves. Physicians who do not accept assignment cannot charge patients more than 15 percent above what Medicare approves. Some states have outlawed balance billing for Medicare beneficiaries at even lower percentages.

If you are eligible for both Medicare and an employer’s group policy (either yours or your spouse’s) the group insurance is usually primary and Medicare is secondary. That is, the group plan covers the costs first, and if some are not covered, then Medicare may cover those costs. There are exceptions to this rule, so you should verify the coordination of your benefits with the administrator of your group benefits.

Medicare Part B covers some specific cancer-related services. These are:

• Annual screening mammograms (starting at age 40).
• Routine pap smear every three years, with no deductible.
• Screening pelvic exams every two years, or every year for women considered at “high risk” for ovarian cancer, with no deductible.
• Annual colorectal cancer screening for people age 50 and older.
• Annual prostate cancer screening for men age 50 and older.
• Limited physical, speech, and occupational therapy.
• Limited prosthetic devices, including breast prostheses and surgical bras.
• Ostomy products.
• Routine healthcare costs for beneficiaries involved in a clinical trial, including hospital and physicians’ visits, routine lab tests, and costs resulting from problems associated with participation in the trial.
• Clinical laboratory procedures—such as blood tests, urine tests, and cultures.
• Chemotherapy drugs that are injected intravenously or by intravenous pump, chemotherapy drugs you can take in pill form if they are also available as injectable or infusible drugs, and certain anti-nausea drugs.

Part B does not cover:

• Routine annual physicals unless you have a specific diagnosis. However, as of 2006, Medicare now covers 80% of the approved amount of an initial preventive physical exam during the first six months after enrollment in Part B.
• Private duty nursing.
• Any services provided outside of the United States, unless you are close to the border of Canada or Mexico and the closest hospital is in one of those countries.
• Prescription drugs, with a few important exceptions that are mentioned above. Medicare coverage of prescription drugs is described in the section on Part D.
• Syringes or insulin for diabetic patients.
• Custodial care, such as help with bathing, eating, and getting dressed.

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Medicaid

Medicaid is a government program that provides health insurance for low-income people and families. Each state has its own Medicaid program with its own rules about whom and what it covers. However, because the federal government helps states fund their Medicaid programs, there are some national rules that apply everywhere.

In most states, in addition to having very low income, you must be a child, a parent of dependent children, elderly, or disabled to qualify for Medicaid. Some states, though, do cover lowincome adults who are not elderly, disabled, or parents.

Since 1991, each state has the option to make uninsured women with breast and cervical cancer eligible for Medicaid, and all 50 have done so. To be eligible for Medicaid in this way, women must have been screened through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) – services generally provided through clinics or community health centers – and found to have breast or cervical cancer, including precancerous conditions. When states elect this option, coverage for the full range of Medicaid services will be available to these women as long as they are in treatment for breast or cervical cancer. For more information about eligibility for Medicaid for women with breast and cervical cancer, see the CMS website at www.cms.hhs.gov/medicaidspecialcovcond/.

Note also that you may be eligible for both Medicare and Medicaid. If you are eligible for the Qualified Medicare Beneficiary (QMB) or “Medicare Buy-in” program, Medicaid will pay for all Medicare premiums, deductibles, and coinsurance. If you are eligible for the Specified Low- Income Medicare Beneficiary Program (SLMB), Medicare Part B premiums will be covered.

For more information about the Medicaid program in your state, check the government pages of your phone book or visit the Centers for Medicare & Medicaid Services at www.cms.gov.

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Learn more about Medicare and Medicaid:

Medicare Managed Care »

Medicare Prescription Drug Coverage »