Medicare and Your Medicare Rights


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  • Good morning [afternoon, evening]. My name is ______________________, and I’m with the Education and Outreach at Florida Medical Quality Assurance, Inc. Florida Medical Quality Assurance is Medicare’s Quality Improvement Organization for the state of Florida. First, I want to thank (name) for hosting our event, and you for coming. - INFORMATION IN PACKET MEDICARE & YOU 2002 (received in mail) QUESTIONS (write them down)
  • This is what a Medicare card looks like. How many of you have one of these red, white, and blue Medicare cards? You’ll receive one when you are enrolled in Medicare. Social Security will share more about enrollment in Medicare later today. Your card contains your Medicare number. Help us protect the Medicare trust fund by guarding this number as you would your credit card. You can tell whether you’re enrolled in Part A, Part B, or both by looking at the “effective date.” If there is a date under this column and by Part A, you are enrolled in Part A. In this example, we can see that John Doe is enrolled in Part A on January 1, 1995. We can also see from this example, however, that he is not enrolled in Part B as there is not an “effective date” in that row. We’ll talk more about Medicare A and B in a moment.
  • Reference: HCFA 10116, Your Medicare Benefits Let’s now look at the components of Medicare. There are two parts to the Original Medicare plan. They are Hospital Insurance, which is called Part A, and Medical Insurance which is called Part B.
  • MAKING ENDS MEET (premiums, deductibles, co-insurance) Let’s first look at the premium rates. A premium is what you pay monthly for health care coverage to Medicare, an insurance company, or a health care plan (such as HMOs). For Medicare, there is a Part A and a Part B premium. Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare covered employment (quarters where a Medicare tax was taken out of your paycheck). Social Security will talk more about this in their presentation. In addition to any premiums, you also have responsibility for deductibles and coinsurance. Here are the 2001 out-of-pocket expenses that a person with Part A of Medicare might pay. A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital or skilled nursing facility for 60 days in a row. Medicare counts the first day you enter the hospital as the first day of your benefit period. Deductible : the amount you must pay for health care before Medicare begins to pay benefits. There is a deductible for each benefit period for Part A, and for each year for Part B. Coinsurance is a specified dollar amount or percentage of covered expenses which you are required to pay.
  • Let’s look at what you will pay for hospital stays. First, we need to understand what a benefit period is. A benefit period refers to the way that Medicare measures your use of hospital and skilled nursing facility services (SNF). A benefit period begins the day you are admitted to a hospital. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible ($792 in 2001) for each benefit period. There is no limit to the number of benefit periods you can have.
  • The second part of Medicare is Part B, or Medical Insurance. Part B of Medicare covers outpatient hospital care, doctors' services, lab and X-ray tests, ambulance transportation, medical equipment, prosthetics (such as artificial limbs), supplies (such as surgical dressings), and other outpatient services
  • Here’s the out-of-pocket expenses for 2002 that a person with Part B of Medicare might pay. [Go over list presented on slide]
  • Medicare’s Preventive Services (see booklet).
  • Colon cancer is the third most common form of cancer for both men and women in the United States. The Medicare population is at an increased risk simply because of age. These screening tests are now available to all people with Medicare over age 50 and include: Fecal occult blood test—once every 12 months Flexible sigmoidoscopy—once every 48 months Colonoscopy (no age limit)—once every 24 months for those at high risk of colon cancer; once every 10 years for others Barium enema—doctor can substitute for a sigmoidoscopy or colonoscopy Previously, while colorectal cancer screening was a covered preventive service, a colonoscopy was only covered for those at high risk. A new legislative provision authorizes coverage for screening colonoscopies for all individuals, not just those at high risk. For persons not at high risk, payments could not be made for such procedures if performed within 10 years of a previous screening colonoscopy or within 4 years (or 48 months) of a screening flexible sigmoidoscopy. This became effective July 1, 2001. “ High risk individuals” refers to those with family history, prior experiences of cancer, pre-cursor of neo-plastic polyps, or history of a chronic digestive disease condition (e. g., ulcerative colitis, the appropriate gene marker for colorectal cancer, or other predisposing features). Payment rates are different for each test. You pay nothing for the fecal occult blood test. For all other tests, you pay 20% of the Medicare-approved amount after the annual Part B deductible. For flexible sigmoidoscopy or colonoscopy, you pay 25% of the Medicare-approved amount if the test is done in an ambulatory surgical center or hospital outpatient department. Except for skin cancer, prostate cancer is the most common cancer among American men. Medicare already covers prostate-specific antigen (PSA) testing for men with symptoms of prostate disease. This is a diagnostic blood test to detect prostate cancer. Medicare covers screenings every 12 months for prostate cancer for Medicare-eligible men over age 50. This will include the PSA blood test and a digital rectal examination. Medicare will pay 100% of the Medicare-approved amount for the PSA test and 80% of the Medicare-approved amount for the digital rectal examination. A new provision under the Benefits Improvement and Protection Act of 2000 adds Medicare coverage for glaucoma screenings every 12 months for persons determined to be at high risk for glaucoma, individuals with a family history of glaucoma, and individuals with diabetes. The service has to be furnished by or under the supervision of an optometrist or ophthalmologist who is legally authorized to perform such services in the state where the services are furnished. This service will be covered by Medicare beginning January 1, 2002.
  • The goal of today’s session is to help people with Medicare make more informed health care decisions about . . . Medicare program benefits Health plan choices Healthy living We have a lot of material that we’re going to cover today that will help you find out what Medicare can do for you. Let’s take a look at the learning objectives for today’s session 
  • Reference: HCFA 10128, Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
  • Reference: HCFA 10128, Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
  • Medicare and Your Medicare Rights

    1. 1. Medicare and Your Medicare Rights By Sylvia Gaddis Florida Medical Quality Assurance, Inc.
    2. 2. <ul><li>Medicare is a health insurance program for: </li></ul><ul><li>People age 65 or older </li></ul><ul><li>Some people under 65 with disabilities </li></ul><ul><li>Usually required to be eligible for Social Security Disability for at least 2 years </li></ul><ul><li>People with End-Stage Renal Disease (ESRD) (permanent kidney failure) </li></ul><ul><li>People with Lou Gehrig’s Disease (ALS) </li></ul>
    4. 4. <ul><li>“ Hospital Insurance” </li></ul>B A “ Doctor Insurance”
    5. 5. <ul><li>Part A is premium free for most people </li></ul><ul><li>Part A Hospital Deductible </li></ul><ul><ul><li>$812 per benefit period </li></ul></ul><ul><li>Part A Hospital Co-insurance </li></ul><ul><ul><li>Days 1-59 No Co-insurance </li></ul></ul><ul><ul><li>Days 61-90 $203 per day </li></ul></ul><ul><ul><li>Days 91-150 $406 per day </li></ul></ul>
    6. 6. <ul><li>Part A helps pay for things like: </li></ul><ul><ul><li>Hospital Stays </li></ul></ul><ul><ul><li>Nursing Home Care ( Very Limited) </li></ul></ul><ul><ul><li>Home Health Care </li></ul></ul><ul><ul><li>Hospice Care </li></ul></ul>
    7. 7. <ul><li>Part A “Benefit Period” </li></ul><ul><ul><li>You pay only one deductible for each benefit period </li></ul></ul><ul><ul><li>Starts the day admitted </li></ul></ul><ul><ul><li>Ends when no care received for 60 days </li></ul></ul><ul><ul><li>No limit to the number of benefit periods </li></ul></ul>
    8. 8. <ul><li>Part A Nursing Home Care </li></ul><ul><li>For Each Benefit Period: </li></ul><ul><li>Covered in full for 20 days </li></ul><ul><ul><li>(after hospital admission only ) </li></ul></ul><ul><ul><li>Co-insurance </li></ul></ul><ul><ul><ul><li>You pay $99 per day for days 21-100 </li></ul></ul></ul><ul><ul><ul><li>You pay all costs after 100 days </li></ul></ul></ul>
    9. 9. <ul><li>Part B Premium </li></ul><ul><ul><li>$54 per month </li></ul></ul><ul><li>Part B Deductible </li></ul><ul><ul><li>$100 each year </li></ul></ul><ul><li>Part B Coinsurance </li></ul><ul><ul><li>20% of approved amount for most services </li></ul></ul><ul><ul><li>20% of outpatient charges </li></ul></ul>
    10. 10. <ul><li>Part B helps pay for things like: </li></ul><ul><ul><li>Doctors’ Visits </li></ul></ul><ul><ul><li>Outpatient Surgery </li></ul></ul><ul><ul><li>Preventive Health Care </li></ul></ul><ul><ul><li>Outpatient Tests </li></ul></ul><ul><ul><li>Medical Equipment Used at Home </li></ul></ul><ul><ul><li>Ambulance Services </li></ul></ul>
    11. 11. <ul><li>Medigap </li></ul><ul><li>Covers Payment ‘Gaps’ in Original Medicare </li></ul><ul><li>Standardized Plans ‘A’ through ‘J’ </li></ul><ul><li>Sold by Private Insurance Companies </li></ul><ul><li>May Help Lower Out-of-Pocket Costs </li></ul>
    12. 12. <ul><li>Covered Services </li></ul><ul><li>Ambulance </li></ul><ul><li>Artificial eyes </li></ul><ul><li>Artificial limbs </li></ul><ul><li>Braces - arm, leg, back, and neck </li></ul><ul><li>Chiropractic services (limited) </li></ul><ul><li>Emergency care </li></ul><ul><li>Eyeglasses (one pair after cataract surgery ) </li></ul>
    13. 13. <ul><li>Covered Services </li></ul><ul><li>Immunosuppressive drug therapy </li></ul><ul><li>Kidney dialysis </li></ul><ul><li>Macular degeneration treatment </li></ul><ul><li>Medical nutrition therapy </li></ul><ul><li>Medical supplies </li></ul><ul><li>Prosthetic devices </li></ul><ul><li>Transplants </li></ul>
    14. 14. Therapy Coverage of Alzheimer’s Disease Patients Statement 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.”
    15. 15. <ul><li>Therapy Coverage of Alzheimer’s Disease Patients </li></ul><ul><li>Statement of Tom Scully, Administrator </li></ul><ul><li>Centers for Medicare & Medicaid Services </li></ul><ul><li>Medicare provides payment for the following: </li></ul><ul><ul><li>specific speech therapy </li></ul></ul><ul><ul><li>occupational therapy </li></ul></ul><ul><ul><li>rehabilitation therapy </li></ul></ul><ul><ul><li>neuro-diagnostic testing </li></ul></ul><ul><ul><li>medication management </li></ul></ul><ul><ul><li>psychological therapy </li></ul></ul><ul><li>The memorandum from Mr. Scully is available at </li></ul>
    16. 16. <ul><li>Preventive Healthcare </li></ul><ul><li>Diabetes Monitoring </li></ul><ul><li>Nutritional Therapy </li></ul><ul><ul><li>For those with Diabetes/Kidney Disease </li></ul></ul><ul><li>Glaucoma Screening </li></ul><ul><li>Flu (influenza) shot </li></ul><ul><li>Pneumonia Vaccination </li></ul><ul><li>Hepatitis B Vaccination </li></ul>
    17. 17. <ul><li>Preventive Healthcare </li></ul><ul><li>Colon Cancer Screening </li></ul><ul><li>Prostate Cancer Screening </li></ul><ul><li>Mammogram Screening </li></ul><ul><li>Bone Mass Measurements </li></ul><ul><li>Pap Tests/Pelvic Exams </li></ul>
    18. 18. <ul><li>Non-covered Services </li></ul><ul><li>Acupuncture </li></ul><ul><li>Dental care and dentures </li></ul><ul><li>Cosmetic Surgery </li></ul><ul><li>Custodial Care at home or in Nursing Home </li></ul><ul><li>Health care while traveling outside the USA </li></ul><ul><li>Hearing aids and hearing exams </li></ul><ul><li>Orthopedic shoes </li></ul>
    19. 19. <ul><li>Non-covered Services </li></ul><ul><li>Outpatient prescription drugs (with a few exceptions) </li></ul><ul><li>Routine foot care (with only a few exceptions) </li></ul><ul><li>Routine eye care and most eyeglasses </li></ul><ul><li>Routine or yearly physical exams </li></ul><ul><li>Screening tests </li></ul><ul><ul><li>except those listed as covered preventive services </li></ul></ul><ul><li>Shots (vaccinations) </li></ul><ul><ul><li>except those listed as covered preventive services </li></ul></ul>
    20. 20. <ul><li>Medicare Rights </li></ul><ul><li>If you have Medicare, you have certain guaranteed rights and protections. </li></ul><ul><li>You have these rights whether you have the Original Medicare Plan, a Medigap policy, a Medicare HMO. </li></ul>
    21. 21. <ul><li>Medicare Rights </li></ul><ul><li>Respect </li></ul><ul><li>Protection Against Discrimination </li></ul><ul><li>Easy to Understand Information </li></ul><ul><li>Emergency care </li></ul><ul><li>Treatment Choices </li></ul><ul><li>Privacy of Personal Information </li></ul><ul><li>Privacy of Health Information </li></ul><ul><li>Culturally Competent Services </li></ul>
    22. 22. <ul><li>Medicare Rights </li></ul><ul><li>Appeals </li></ul><ul><li>Billing, Payment, or Services </li></ul><ul><li>Grievances </li></ul><ul><li>Quality of Care Issues </li></ul>
    23. 23. <ul><li>Medicare Rights </li></ul><ul><li>Appeal a Hospital Discharge if you feel you </li></ul><ul><li>are too sick to leave </li></ul><ul><li>You do NOT have to leave the hospital </li></ul><ul><li>You do NOT have to pay for the extra days you are in the hospital while we look at your medical record. </li></ul>
    24. 24. Thank You! If you have questions, call 1-800-MEDICARE