Medicare
Medicare is a Health insurance Program for:
Part A (Hospital insurance)
Here are some simple guidelines. You can get Part A at
age 65 without having to pay premiums if:
If you are under 65, you can get Part A without having
to pay premiums if:
Helps Pay For:
Care in hospitals as an inpatient, 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 health care. Information about
your coverage under Medicare Part A can be found in the
Your
Medicare Coverage database.
Cost:
Most people get Part A automatically when they turn age
65. They do not have to pay a monthly payment called a
premium for Part A because they or a 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. If you are not sure you have Part
A, look on your red, white, and blue Medicare card. It
will show "Hospital Part A" on the lower left
corner of the card. You can also call the Social Security
Administration toll free at 1-800-772-1213 or call or
visit your local
Social Security office for more information about
buying Part A. If you get benefits from the Railroad Retirement
Board, call your local RRB office or 1-800-808-0772.
For More Information About Medicare Part A Coverage:
Visit the Your
Medicare Coverage database.
Call your Fiscal Intermediary about Part A bills and
services. The phone number for the Fiscal Intermediary
in your area can be found in the Helpful
Contacts section of cms.gov website.
Part B (Medical insurance)
Helps Pay For:
Doctors' services, outpatient hospital care, and some
other medical services that Part A does not cover, such
as the services of physical and occupational therapists,
and some home health care. Part B helps pay for these
covered services and supplies when they are medically
necessary. Information about your coverage under Medicare
Part B can be found in the Your Medicare Coverage database.
Cost:
You pay the Medicare Part B premium of $66.60 per month
in 2004. This amount may change January 1, 2004. In some
cases this amount may be higher if you did not choose
Part B when you first became 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.
Enrolling in Part B is your choice. You can sign up for
Part B anytime during a 7-month period that begins 3 months
before you turn 65. Please call the Social Security Administration
at 1-800-772-1213 or visit or call your local
Social Security office to sign up. 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 3 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. If you get benefits from the
Railroad Retirement Board, call your local RRB office
or 1-800-808-0772.
For More Information About Medicare Part B Coverage:
Visit the Your
Medicare Coverage database.
Call your Medicare Carrier about bills and services.
The phone number for the Medicare Carrier in your area
can be found in the Helpful
Contacts section.
You may have choices in how you get your health care
including the Original Medicare Plan, Medicare Managed
Care Plans (like HMOs), and Medicare Private Fee-for-Service
Plans.
My.Medicare.gov
My.Medicare.gov
(Medicare Beneficiary Portal) is an interactive tool that
provides beneficiaries with direct internet access to
their Medicare claims information, including claims type,
dates of service, and procedures. It also provides beneficiary-related
preventive health information. My.Medicare.gov is currently
being piloted to residents of Indiana.
How to File a Claim
If you are in the Original Medicare Plan, providers (e.g.,
hospitals, skilled nursing facilities, home health agencies,
and physicians) and suppliers are required by law to file
Medicare claims for covered services and supplies that
you receive. You should not need to file any Medicare
claims. Medicare claims must be filed within one full
calendar year following the year in which the services
were provided. For example, if you see your physician
on March 22, 2004, the Medicare claim for that visit must
be filed by December 31, 2005.
Is your pharmacy or supplier enrolled in Medicare?
If the answer is no, you will be responsible for the
entire bill for any drugs or supplies purchased. Important
information you need to know before you make your
purchase.
Note: This information on filing a Medicare claim
only applies if you are in the Original Medicare Plan.
If you get your Medicare health care through a Managed
Care Plan or a Private Fee-for-Service Plan, Medicare
claims are not filed. Medicare pays these private insurance
companies a set amount every month. Therefore, they do
not need to file Medicare claims.
My Provider or Supplier Accepts Medicare Assignment
You pay your share of the bill (coinsurance and deductibles)
to the provider or supplier. The provider or supplier
files a Medicare claim. Medicare pays its share of the
bill directly to the provider or supplier.
My Physician or Supplier Does Not Accept Medicare
Assignment
Note: Only physicians and suppliers can decide
not to accept assignment.
If your physician or supplier does not accept assignment
for covered services, your physician or supplier may require
that you pay most or all of the bill at the time you receive
services or supplies. However, the physician or supplier
is still required to file a Medicare claim on your behalf.
Medicare then pays its share of the bill directly to you.
Medicare cannot pay you its share of the bill until a
Medicare claim is filed. You should take the following
steps if your doctor or supplier does not file the Medicare
claim in a timely manner.
Step 1 - Contact Your Physician or Supplier: Call
your physician or supplier directly and ask the physician
or supplier to file a Medicare claim.
Step 2 - Contact Your Local Medicare Carrier: If
your physician or supplier still does not file a Medicare
claim after you have called and asked, you should call
your local Medicare Carrier. The Medicare Carrier phone
number can be found in our Helpful
Contacts section of the medicare.gov web site. Your
local Medicare Carrier will contact the physician or supplier
on your behalf to make the physician or supplier aware
of the responsibility for filing a Medicare claim. Also
ask the Medicare Carrier for the exact time limit for
filing a Medicare claim for the service or supply that
you received.
IMPORTANT: There is a time limit for filing a
Medicare claim. If a claim is not filed within this time
limit, Medicare cannot pay you its share. The time limit
may be as short as 15 months or as long as 27 months depending
on when you received the service or supply. It is important
that you ask the Medicare Carrier what the time limit
is for filing your claim.
Step 3 - When You Should File a Claim: You should
only need to file a Medicare claim in very rare situations.
You should contact your local Medicare Carrier and ask
for the forms to file a Medicare claim yourself when:
-
you have completed steps 1 and 2 above;
AND
-
the physician or supplier still has
not filed the Medicare claim; AND
-
it is close to the time limit for filing
your Medicare claim. (For example, if your time limit
is 15 months, you should consider filing a Medicare
claim if the physician or supplier has not filed the
Medicare claim 12 months after you received the service
or supply).
To file a Medicare claim yourself, call your local Medicare
Carrier and ask for the proper form for a Medicare beneficiary
to file a claim. Your Medicare Carrier can also answer your
questions about how to complete the claim form.
For more information about assignment, read the brochure:
Does
Your Doctor or Supplier Accept Assignment? For a list
of physicians in your area who always accept assignment,
use the Participating
Physician Directory on the Medicare.gov
website.
Medicare Appeals and Grievances
Your Medicare Appeal Rights:
You have the right to appeal any decision about your Medicare
services. This is true whether you are in the Original Medicare
Plan or a Medicare managed care plan. If Medicare does not
pay for an item or service you have been given, or if you
are not given an item or service you think you should get,
you can appeal.
Appeal Rights Under the Original Medicare Plan:
If you are enrolled in the Original Medicare Plan, you can
file an appeal if you think Medicare should have paid for,
or did not pay enough for, an item or service you received.
If you file an appeal, ask your doctor or provider for any
information related to the bill that might help your case.
Your appeal rights are on the back of the Explanation of
Medicare Benefits or Medicare Summary Notice that is mailed
to you from a company that handles bills for Medicare. The
notice will also tell you why your bill was not paid and
what appeal steps you can take.
Appeal Rights Under Medicare Managed Care Plans:
If you are in a Medicare managed care plan, you can file
an appeal if your plan will not pay for, does not allow,
or stops a service that you think should be covered or provided.
If you think your health could be seriously harmed by waiting
for a decision about a service, ask the plan for a fast
decision. The plan must answer you within 72 hours.
The Medicare managed care plan must tell you in writing
how to appeal. After you file an appeal, the plan will review
its decision. Then, if your plan does not decide in your
favor, the appeal is reviewed by an independent organization
that works for Medicare, not for the plan. See your plan's
membership materials or contact your plan for details about
your Medicare appeal rights.
If you have concerns or problems with your plan which are
not about payment or service requests, you have a right
to file a grievance. For example, if you believe your plan's
hours of operation should be different, you can file a grievance.
You are protected when you are in the hospital:
This is true whether you are in the Original Medicare Plan
or a Medicare managed care plan. If you are admitted to
a Medicare participating hospital, you should be given a
copy of An Important Message From Medicare. It explains
your rights as a hospital patient. If you are not given
one, ask for it.
The Message tells you:
- You have the right to get all of the hospital care that
you need, and any follow-up care after you leave the hospital.
- What to do if you think the hospital is making you leave
too soon.
If you have questions about this, call 1-800-MEDICARE.
If you ask a Quailty Improvement Organization (QIO) to review
your case, you may be able to stay in the hospital at no
charge during the review. The hospital cannot force you
to leave before the QIO makes a decision.
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
