Medicare is a health insurance program for:
- people age 65 or older
- people under age 65 with certain disabilities, and
- people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
- Medicare Part A (Hospital Insurance)
- Medicare Part B (Medical Insurance), and
- Medicare prescription drug coverage (Part D
What is Medicare Part A?
Medicare Part A helps cover your inpatient care in hospitals and skilled nursing facilities when they are medically necessary.
Limited nursing home and home-care benefits for those who need skilled nursing services and meet other eligibility criteria are covered. Most long-term care is not covered
Medicare Coverage of Skilled Nursing Facility Care
What is Medicare Part B?
Medicare Part B helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover. Services are covered when medically necessary.
- Original Medicare Plan
Note: People using the basic Medicare Plan may choose to supplement coverage with a Medigap policy which is designed to "cover the gaps" in coverage. The gaps are considered things like coinsurance, deductibles, and co-payments.
- Medicare Advantage Plans
Note: If you have one of these plans, you don't need a Medigap policy.
These plans include:
- Medicare Managed Care Plans (like HMOs)
- Medicare Preferred Provider Organization Plans (PPOs)
- Medicare Private Fee-for-Service Plans (PFFS)
- Medicare Special Needs Plans
You would make your choice about the plan that is right for you by comparing things like:
- doctor choice
Medicare offers Options Compare to help you narrow down your Medicare health plan choices and choose the plan that's best for you.
Medicare publishes brochures to help you understand your benefits and eligibility for benefits (to follow is a partial list; there are many more). You can obtain these publications through the Medicare office, through your local Social Security office or access them online. 1-800-633-4227
Medicare Basics - a Guide for Caregivers
Medicare Home Health Coverage
Medicare Hospice Benefits
Medicare on Nursing Home Benefits
Your Medicare Benefits
Medicare is part of the Social Security program. You may find the information you need through your local Social Security office. If you need assistance locating your local Social Security office, contact the Social Security Locator Service. You will type in your zip code and contact information will be located for you. Or, you may call and speak to a Social Security representative.
The National Council on the Aging offers a special online service called BenefitsCheckup to help. You enter a limited amount of confidential personal information and benefits that you may be entitled to are identified for you.
In North Carolina, you would then need to follow-up with your local Department of Social Service to ensure eligibility and to apply.
|If you need Home Health, Medicare offers a tool called Home Health Compare. This tool compares Medicare certified Home Health Agencies in your area.|
Seniors Health Insurance Information Programs (SHIIP)
Perhaps the easiest way to choose what plan is right for you is to get help from a trained volunteer. For questions and assistance understanding the many complexities of Medicare, most states offer a Seniors Health Insurance Information Program (the name of the program may vary from state to state). They offer the help of trained volunteers to answer your questions and to offer counseling.
These programs were established in 1990 and are funded by grants from the US Department of Health and Human Services and/or funding from state government. They are authorized by federal law to provide information, referrals, and counseling to Medicare beneficiaries and their caregivers on a wide range of health access and insurance matters. They are typically administered by either the state aging agency or the state Division of Insurance. Services are provided locally through the trained volunteer network.
Medicare offers several programs for people who make too much money to qualify for Medicaid, the health insurance program for the economically disadvantaged, but make too little to comfortably pay the premiums for Medicare Part B, which pays for doctor visits.
They offer "Medicare Savings Programs". Currently, there are three different programs. These programs may pay some or all of the Medicare premiums and may pay deductibles and coinsurance. Be sure to ask about them.
Call 1-800-MEDICARE (1-800-633-4227).
|Qualified Medicare Beneficiary (QMB)|
|Specified Low-Income Medicare Beneficiary (SLMB)|
|Qualifying Individual (QI-1) (temporary program)|
In North Carolina, the Medicaid-Aid Benefit helps people cover Medicare costs. Eligibility is based on your income. A benefit like this North Carolina benefit may be available in other states. Check with your local Area Agency on Aging.
North Carolina also offers assistance with Medicare Part D - the Prescription Drug Benefit - premiums. The program is called NCRx.
Another consideration is Medicare Supplemental Insurance or Medigap. This insurance is sold by insurance companies like other insurance and is designed to help with expenses not covered by Medicare. Medigap policies pay most, if not all, Medicare coinsurance amounts and may provide for Medicare deductibles. Some of the 10 standard policies pay for services not covered by Medicare, such as outpatient prescription drugs and preventive screening.
You may want to consider a Medicare SELECT policy, which is a Medigap policy in which you are required to use certain hospitals and doctors. The SELECT policies generally have lower premiums than other Medigap policies. These policies are not available in all states.
When you first enroll in Medicare at age 65 or older, you have a six-month “Medigap open enrollment period.” During that time, you have a right to buy the Medigap policy of your choice regardless of any health problems you may have. The company cannot refuse you a policy or charge you more than other open enrollment applicants.
The Medicare government website offers these online booklets or call 1-800-MEDICARE.
You can also select Medicare Options Compare on the Medicare website to compare the Medigap policies available in your area. The government website is easy to use and offers a wealth of information about your choices.
The New York State SHIIP program offers an excellent website with information for both counselors and consumers. It is called the Medicare Rights Center. The center is funded through various private foundations and from support from the New York State Office on the Aging.
The Center offers a Medicare Hotline. The number is 1-800-333-4114. Ask an online question through "Dear Marci" and receive the answers via email. They also have online search capabilities so that you can find the answers to your questions online.
The service was set up to serve New York residents but they will help anyone who calls. Medicare rules and regulations are consistent from state to state so the information will be useful to residents of any state. Please note that Medicaid may be different from state to state.
The N.Y. SHIIP office can be reached at 1-800-333-4114 or you may link to their website.
Most states have a process to monitor quality of care for Medicare recipients. For information on who provides this service, how it works, and how to be connected, contact your Senior Health Insurance Information Program.
In NC, Carolinas Center for Medical Excellence (formerly Medical Review of North Carolina, Inc.) has a contract with the federal government to make sure that Medicare patients receive quality medical care. The Center is made up of practicing doctors, nurses and health care professionals who review patient care.
Center for Medical Excellence
P.O. Box 37309
Raleigh, NC 27627-7627
For Information About Medicare Claims for North Carolina:Medicare Part A
Government Benefits Administrators
Medicare Part B
Durable Medical Equipment and Supplies
Health Insurance Information Program (SHIIP)
For information on how to proceed further, contact your Senior Health Insurance Information Program.
If your claim relates to a long-term care facility, you may also contact your Ombudsman Program or Area Agency on Aging.
In North Carolina, as part of the NC Patient's Bill of Rights and housed within the Consumer Protection Division of the Attorney General's Office, citizens have the Managed Care Patient Assistance Program to assist with health insurance issues. This program can offer advice about appeals, coverage, and explain individual policy benefits related to managed care. Contact them at 1-866-867-6272.
If your Medicare claim for long-term care service has been denied and you wish to appeal the decision, contact The Carolinas Center for Medical Excellence. The phone number is 1-800-722-0468. The long-term care resident cannot be discharged while an appeal with The Center is in process.
As a caregiver, dealing with all the complexities of paying for care can become overwhelming. There is help available. You don't have to do it by yourself.
Caregiver Specialists are trained individuals that are hired by local aging agencies or counties to help you. Area Agencies on Aging may have a Caregiver Specialist as well. Their services are provided as a service though you may make a voluntary contribution.
Their job is to understand the challenges you face and to be able to help you connect to available resources and information. They will help you help both your family member and yourself.
|Remember to be completely honest with them. Don't be embarrassed to share with them how you are feeling and coping with your situation and any specific problems you may be having. Anything you share will be held in confidence and they will not judge you or the situation you find yourself in. They want to help you which is why they have chosen this career.|
Personalized assistance is available in every state through the Older American's Act and the Family Caregivers Support Program. States may vary slightly in the way assistance is offered so it is best to check with the Area Agency on Aging serving the county in which the person needing assistance lives. Ask for contact information for a Caregiver Specialist or an Information and Referral Specialist. You can also check with any local Senior Center in the area. They should know what is available locally. And, there is always the State Aging Agency which will have statewide information available.
Care Managers are another option for assistance. Please recognize that care managers are professionals who will provide services that you pay for. Be sure to ask appropriate questions before entering into an agreement for service. Questions could include experience, years in the business, training, etc. Also, feel free to ask for references.
|More on Care Managers|
|Find Your Area Agency on Aging|
|Find Area Agencies on Aging in NC|
|Caregiver Specialists in NC|
|Find Your State Aging Agency|
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 brings the most sweeping changes to the Medicare program since it began in 1965.
The intent of these changes is for Medicare to offer more affordable health care, prescription drug coverage, expanded health plan options, improved health care access for rural Americans, and preventive care services for Medicare recipients.