Medicare

Original Medicare Plan

Medicare is a federal health insurance program for people 65 or older, those with disabilities and end stage renal disease. It is made available regardless of financial need. The Original Medicare Plan is comprised of two parts: Part A and Part B. Part A is hospital insurance, which covers inpatient hospital care, nursing facility care, hospice care and home health care. There are deductibles and coinsurance payments under Part A, but generally there is no premium. Part B covers doctors’ services, outpatient services, medical equipment and other services not covered under Part A. Enrollment in Part B is voluntary and premiums, deductibles and coinsurance must be paid directly by the patient or through another insurance plan.

Part A

Medicare Part A covers inpatient hospital stays, skilled nursing facility care, home health care and hospice care. For each benefit period, individuals receive up to 150 days of inpatient hospital care. Individuals must pay a deductible for a hospital stay of 1-60 days. Individuals must pay a daily payment for days 61-90 and 91-150 of a hospital stay. All costs beyond 150 days are the responsibility of the patient. If you have any questions about the quality of care in hospitals, call 1-800-MEDICARE or 1-800-633-4227.

Hospice care is also covered under Part A, but only if three criteria are met: (1) Doctor must certify that the patient is terminally ill; (2) Patient must choose hospice care; and (3) Care must be provided by a Medicare participating hospice. Medicare generally does not pay for room and board except in certain cases.

Skilled nursing care is also covered under Part A. Patients pay nothing for the first 20 days of care. Patients pay a daily payment for 21-100 days of care. The patient must cover all costs beyond the 100th day in a benefit period.

Part A also pays for blood after the patient pays for the first three pints, unless the patient or someone else donates blood to replace what the patient uses.

Finally, Part A covers home health services. Patients pay nothing for Medicare-approved services and 20% of the Medicare-approved amount for durable medical equipment. Like the hospice coverage provision, Part A will only cover home health services if certain criteria are met: (1) Care needed by the patient includes intermittent skilled nursing care, physical therapy or speech therapy; (2) Patient is homebound; (3) Patient is under the care of a physician who determines a need for home care and the physician actually establishes a home care program; and (4) Home health agency used by patient must be approved by the Medicare program.

Part B

Medicare Part B covers medically necessary and preventative services such as medical and other services, clinical laboratory services, home health care, blood, ambulance, durable medical equipment, and outpatient hospital services. Patients pay a deductible per calendar year under Part B. This amount can change each year. Patients also pay 20% of the Medicare-approved amount after the deductible once a doctor, provider, or supplier accepts “assignment.” Assignment is an agreement between people with Medicare, their doctors and suppliers, and Medicare. The person with Medicare agrees to let the doctor or supplier request direct payment from Medicare for covered Part B services, equipment, and supplies. Doctors or suppliers who agree to accept assignment from Medicare cannot try to collect more than the proper Medicare deductible and coinsurance amounts from the person with Medicare.

Patients pay nothing for Medicare-approved clinical laboratory services. Certain home health care services are paid under Part B but patients pay 20% of the Medicare-approved amount for durable medical equipment. Patients pay a coinsurance or copayment amount, which may vary according to the service, for outpatient hospital services.

Certain preventive services are also covered under Part B, including: (a) bone mass measurements; (b) cardiovascular screening blood tests; (c) colorectal cancer screening; (d) diabetes services; (e) glaucoma testing; (f) pap test and pelvic examination, including a clinical breast exam; (g) prostate cancer screening; (h) screening mammograms; (i) shots/vaccinations; and (j) a “Welcome to Medicare” wellness visit. Many of these covered services are subject to coinsurance.

Medicare Advantage Plans: Part C

Medicare Advantage plans are known as Part C of Medicare. Under Medicare Advantage, Medicare contracts with private organizations to handle your Medicare Part A and B benefits.  Each year a Medicare Advantage contract may be renewed, changed or terminated.  You are eligible to enroll in Medicare Advantage if you are enrolled in both Medicare part A and B and reside in the plans area.

Medicare Advantage plans include the following choices for coverage: (1) Managed Care Plans-Medicare HMO; (2) Preferred Provider Organization Plans (PPOs); (3) Private Fee-For-Service Plans (PFFs); and (4) Special Needs Plans.

In most HMO Plans, patients can only go to doctors, specialists or hospitals in their plan’s “network” except in an emergency. People may also have to choose a primary care doctor and get referrals to see a specialist. It may be possible to pay lower copayments and get extra benefits, such as coverage for extra days in the hospital.

In most Preferred Provider Organization Plans, patients use doctors, specialists and hospitals in the plan’s network. It may cost extra, but patients are allowed to visit doctors, specialists and hospitals not in the network. Patients are also not required to get referrals for visits outside of the network. It may be possible to pay lower copayments and get extra benefits, such as coverage for extra days in the hospital.

In most Fee-for-Service Plans, patients can visit any doctor or hospital that accepts the terms of the plan’s payment. The private company, rather than the Medicare program, decides how much it will pay and how much the patient pays for services rendered. It may be possible to receive extra benefits, such as coverage for extra days in the hospital.

Special Needs Plans, if available, provide more focused and specialized care for specific people. In Iowa, this plan is available to people who have both Medicare and Medicaid, chronic health conditions or live in a nursing facility or assisted living facility. People joining these plans get all of their Medicare health care as well as more focused care to manage a specific disease or condition.

Medicare Prescription Drug Plans: Part D

Medicare contracts with private companies to offer prescription drug coverage. These plans are voluntary and people are not automatically enrolled in a plan. Coverage is available under the Original Medicare Plan and certain Medicare Advantage Plans.

People will pay a monthly premium in addition to any premiums for Medicare Part A and B.

Note that if a person does not join a prescription drug plan when first eligible, they may have to pay higher premiums to join later.

Individuals with limited income and resources will be able to get extra help with their Medicare prescription drug premium and cost sharing. To apply for the extra help contact the Social Security Administration, 1- 800-772-1213.

General questions on Iowa’s programs and coverages can be directed to the Senior Health Insurance Information Program (SHIIP) at 1-800-351-4664 or by visiting www.shiip.iowa.gov