Where to Turn... Your Guide to Federal Disability Policies and Programs Authors Patrice Drew, Esq. Cathy Ficker Terrill Anne C. Parrette, Esq. Project Coordinator Janna Starr Editors Larry H. Hoffer Lisa Ward Monique Marino Brain Injury Association US Department of Health and Human Services HRSA Health Resources and Services Administration Maternal and Child Health Bureau Disclaimer The Brain Injury Association shall not be held liable for content changes made by unauthorized parties, including but not limited to: alterations of text, images or other information within Where to Turn: Your Guide to Federal Disability Policies and Programs (the Guide.) The Guide contains general information. It is not an authoritative legal document, nor shall it be construed as legal advice. The Guide shall not be relied upon as a legal authority for acting or refusing to act. The information contained in the Guide may change as Federal polices and programs are amended periodically. The Brain Injury Association is not responsible for notifying the Public of these changes. Medicare What is Medicare? Medicare What is Medicare? Medicare is a federal health insurance program for people 65 years or older and many other individuals with disabilities. Medicare has two parts: Part A and Part B. Part A covers hospital services. Most people do not have to pay for Part A. Part B covers physician services, outpatient hospital care and laboratory services. A monthly premium is deducted from a beneficiary's Social Security check. In addition, you pay an annual deductible of $100 and 20% of the amount Medicare approves for your medical bills. Am I Eligible for Medicare? Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are at least 65 years old and a citizen or permanent resident of the United States. If you are under 65, you still may qualify for Medicare if you are a person with a disability or chronic kidney disease. You qualify for Medicare if: You are 65 years or older, or If you are under 65, have a disability, or Have chronic kidney disease What are my choices in getting my health care through Medicare? You have two health care delivery options through Medicare: 1. The Original Medicare Plan: Under this plan, a beneficiary can go to any doctor, specialist or hospital that accepts Medicare. Medicare pays a share of your health care costs and the beneficiary pays a portion. Although this is the means by which most beneficiaries receive their Medicare Part A and Part B benefits, certain options, like prescription drugs, are not covered. 2. Medicare Managed Care Plans: Otherwise known as Medicare+Choice, these managed care plans are available in some areas of the country. Like many managed care organizations, beneficiaries may only go to the plan's doctors, specialists or hospitals. All participating plans are required to cover all Medicare Part A and Part B benefits. Some plans even cover prescription drugs. Do I have to pay a premium? You can get Part A at 65 without having to pay premiums if: You already are receiving retirement benefits from Social Security or the Railroad Retirement Board OR You are eligible to receive Social Security or Railroad benefits but have not yet filed for them OR You or your spouse had Medicare-covered government employment While you do not have to pay a premium for Part A if you meet one of those conditions, you must pay for Part B if you want it. In 2000, the monthly premium for Part B is $45.50. This amount is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. What Does Medicare Part A Cover? Medicare Part A covers much of the cost of: Inpatient hospital care Skilled nursing facility care Home health care Hospital care Inpatient Hospital Care Part A covers hospital stays, including psychiatric hospital stays. You are covered for up to 90 days of hospital care per benefit period. A "benefit period" begins when you have been admitted to the hospital and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row. A new benefit period begins with your next hospital admission. Part A also includes partial coverage for 60 additional hospital days in your lifetime, which are called "lifetime reserve" days. Medicare pays for lifetime reserve days only after you've used your Medicare hospital coverage through day 90. You do not have to use your 60 lifetime reserve days all at once. For inpatient psychiatric services in a psychiatric hospital, there is a 190-day lifetime reserve limit. Inpatient Hospital Care per benefit period: 2000 Days 1-60 You pay: $768 deductible per benefit period Medicare Pays: Balance Days 61-90 You pay: $192 per day Medicare Pays: Balance Days 91-150 You pay: $384 per day Medicare Pays: Balance All additional days You pay: Everything Medicare Pays: Nothing What does your Hospital Benefit cover? Bed and Board Routine Nursing Services Medical Social Services Drugs and injections for use in the hospital Equipment and medical supplies Inpatient physical therapy Planning for follow-up care The services of residents and interns What does your Hospital Benefit NOT cover? Luxury items Private-duty nursing Private rooms (unless medically necessary) Television rentals Telephone rentals Skilled Nursing Facility Care While in a Skilled Nursing Facility (SNF) setting, you are offered a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. Part A covers up to 100 days of care in a Medicare-certified skilled nursing facility per benefit period. You must meet three conditions: You must need daily skilled nursing or rehabilitation services. "Daily" is defined as seven days per week for skilled nursing services and five days per week for skilled rehabilitation services. The services you need must be services that, as a practical matter, can be provided only in an inpatient facility. The skilled nursing facility care begins within 30 days of your discharge from a hospital after a stay of at least three days. If the skilled nursing facility claims that Medicare won't pay for your care and makes you sign documentation agreeing to pay for your nursing care yourself, you can demand that the facility bill Medicare directly. The facility cannot charge you unless and until Medicare denies coverage. Skilled Nursing Facility Care Per Benefit Period: 2000 Days 1-20 You pay: Nothing Medicare Pays: Everything Days 21-100 You pay: $97 per day Medicare Pays: Balance All additional days You pay: Everything Medicare Pays: Nothing Home Health Care Home Health Care services consists of intermittent skilled nursing care, physical therapy, speech language pathology services, home health aide services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and supplies, and other services. Home Health Care Services Per Benefit Period: 2000 Days 1-20 You pay: Nothing Medicare Pays: Everything Days 21-100 You pay: $97 per day Medicare Pays: Balance All additional days You pay: Everything Medicare Pays: Nothing Part A covers up to 100 home health care visits if you need care at home within 14 days after a hospital stay of at least three days. (Part B covers home health care if you don't meet the hospital stay requirement or if you need more than 100 visits.) To be eligible for the home health benefits (Part A or Part B), you must meet all three of these conditions: You must be considered homebound. This means that you must have a condition resulting from illness or injury that makes it very hard to leave home. You must get care from a Medicare-certified home health agency. You must need the services of a skilled nurse or a speech, physical or occupational therapist on an intermittent or part-time basis. Intermittent care is skilled care provided fewer than seven days per week or daily for a finite, predictable time. Part-time care is fewer than eight hours per day, usually for periods of 21 days or less. What is covered? Part A (or B) will cover skilled nursing and home health aide services on an intermittent or part-time basis; that is, up to seven days per week as long as services don't exceed eight hours per day and 28 hours per week (sometimes up to 35 hours per week). They also will cover needed home health aide services, physical, speech and occupational therapy, as well as medical social services and supplies. What is your contribution? The home health benefit is available at no cost to those who are eligible (as described above). However, patients must pay the 20% coinsurance for durable medical equipment. Hospice Care Hospice care includes pain and symptom relief, and supportive services for the management of a terminal illness. What is covered? Part A covers hospice services if you're expected to die within six months. Hospice services can be provided for two 90-day periods and an unlimited number of additional 60-day periods. You or your health care guardian must indicate in writing your decision to receive hospice care instead of other Medicare benefits. What is your contribution? Deductibles and coinsurance don't apply to hospice care. You must pay 5% of the charge for outpatient prescription drugs (up to $5 per prescription) and 5% of the cost of inpatient respite care (up to a maximum of $768). Inpatient respite care is time you spend in a hospice facility to allow your caregiver to rest. Medicare covers no more than five respite days in a row. Part B covers the following: physician services, outpatient hospital care, and laboratory services Remember, if you don't enroll in Part B when first eligible and you don't qualify for an exemption or a special enrollment period, you must pay a 10% premium penalty for each year you wait to enroll A monthly premium is ordinarily deducted from your Social Security check. You also must pay an annual deductible of $100 and 20% of the amount Medicare approves for your medical bills Services: Doctors Part B pays for: 80% of the approved charge for most reasonable and necessary doctors' services, except routine checkup Services: Home Health Services Part B pays for: 100% of the cost for up to 35 hours per week of skilled nursing and home health aide services skilled therapy services if you're homebound and require skilled nursing or skilled therapy on a part-time or intermittent basis Services: Preventive Services Part B pays for: annual shots to prevent flu and pneumonia annual mammograms if you're female and over age 40 (the Part B deductible is waived) annual pap smears for high-risk women, one every three years for others (the Part B deductible is waived) bone density measurement colorectal cancer screening if you're over age 50 diabetes self-management: training for patients, glucose monitors and test strips Services: Durable Medical Equipment Part B pays for: 80% of the approved charge for most reasonable and necessary medical equipment you buy from Medicare-certified suppliers (includes wheelchairs, walkers, hospital beds, oxygen, etc.) Services: Outpatient Hospital Services Part B pays for: 80% of the actual charge - typically higher than the approved Medicare charge Services: Physical Therapy Services Part B pays for: 80% of the approved charge for services provided by Medicare-certified independent physical therapists, up to a total of $1,500 a year Services: Laboratory Tests and X-rays Part B pays for: 100% of the approved charge for many reasonable and necessary laboratory tests, and 80% of the approved charge for X-rays required for medical diagnosis Services: Mental Health Services Part B pays for: 50% of the approved charge for most outpatient mental health services Services: Ambulance Services Part B pays for: 80% of the approved charge when an ambulance is needed to take you to or from a hospital or skilled nursing facility because any other method of transportation would be dangerous to your health Services: Blood Part B pays for: 80% of the approved charge for any additional blood after you pay for the first three pints Part B also helps pay for: X-rays Emergency care Speech language pathology services Artificial limbs/eyes One pair of eyeglasses following cataract surgery Breast prostheses following a mastectomy Arm, leg, back and neck braces Ostomy bags, surgical dressings Kidney dialysis and transplants How do I get Part B? You are automatically eligible for Part B if you are eligible for premium-free Part A. You also are eligible if you are a United States citizen or permanent resident, who is age 65 or older. Just before you turn 65 years old, you have to decide whether or not to receive Part B. You should keep in mind that the cost of Part B may increase 10% for each 12-month period that you could have had Part B but did not take it, except in special cases (see "Special Enrollment Period"). You will have to pay this extra 10% for the rest of your life. If you choose to get Part B, the monthly premium is taken out of your Social Security, Railroad Retirement or Civil Service Retirement payment. If you don't get any of these payments, you are billed by Medicare every three months. If you didn't take Part B when you were first eligible, you can sign up during two enrollment periods. The two enrollment periods are: 1. General Enrollment Period: The General Enrollment Period is from January 1 through March 31 of each year. You can sign up for Part A or Part B at your local Social Security Administration office. Your Part B coverage will start on July 1 of that year. 2. Special Enrollment Period: If you didn't take Part B when you first were eligible because you or your spouse were working and had group health plan coverage through your or your spouse's employer or union, you can sign up for Part B during a Special Enrollment Period. You can sign up: Any time you still are covered by the employer or union group health plan through your or your spouse's current or active employment, or Within eight months of the date when the employer or union group health plan coverage ends, or when the employment ends (whichever is first). If you are disabled and working (or you have coverage from a working family member), the Special Enrollment Period rules also apply. Most people who sign up for Part B during a Special Enrollment Period do not pay higher premiums. However, if you are eligible, but do not sign up for Part B during the Special Enrollment Period, the cost of Part B may increase. What Can Doctors Charge Me? Accepting Assignment Doctors are called "participating providers" if they "accept assignment," which means they always accept the Medicare-approved charge as payment in full. They aren't allowed to charge you more than Medicare's approved charge for their services. It's always a good idea to ask doctors in advance whether they'll take assignment. Medicare will pay the doctor 80% of the approved amount and you're responsible for the remaining 20%. Doctors who treat Medicare beneficiaries who also are eligible for Medicaid (dual-eligibles) must accept Medicare assignment. Doctors who don't accept assignment can charge no more than 15% above Medicare's approved amount. This means you pay no more than the extra 15%, plus any required deductible and coinsurance. Some states have stricter limits on doctors' charges. Who Pays the Doctor? When doctors accept assignment You pay: 20% coinsurance Medicare Pays: 20% coinsurance plus up to 15% extra When doctors don't accept assignment You pay: 80% of approved charge Medicare Pays: 80% of approved charge Does Medicare pay for Prescription Drugs? Generally, Original Medicare does not cover prescription drugs. However, Medicare does cover some drugs in certain cases such as immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs. You should call your Durable Medical Equipment Regional Carrier for more information. Check out www.medicare.gov to find the phone number for your Durable Medical Equipment Regional Carrier. There are some Medicare Health Plans that cover prescription drugs. You also can check into getting a Medigap or supplemental insurance policy for prescription drug coverage. Medicaid also may help pay for prescription drugs for people who are eligible. What is a "Medigap" policy and how does it work? A Medigap policy is sold by private insurance companies to fill the "gaps" in Original Medicare Plan coverage. The front of the Medigap policy must clearly identify it as "Medicare Supplement Insurance." In all but three states (Minnesota, Massachusetts and Wisconsin), there are 10 standardized Medigap plans called "A" through "J." Each plan has a different set of standard benefits. Medicare SELECT is a type of Medigap insurance policy. If you buy a Medicare SELECT policy, you are buying one of the 10 standardized Medigap plans A through J (see page 23). When you buy a Medigap policy you pay a premium to the insurance company. As long as you pay your premium, policies bought after 1990 are renewed automatically each year. This means that your coverage continues year after year as long as you pay your premium. You still must pay your monthly Medicare Part B premium. What is not covered by Medigap policies? Long-term care Vision or dental care Hearing aids Private-duty nursing Unlimited prescription drug What do Medigap policies cover? Each standardized Medigap policy must cover basic benefits (see core benefit section). Medigap policies pay most, if not all, of the Original Medicare Plan coinsurance amounts. These policies also may cover the Original Medicare Plan deductibles. Some of the policies cover extra benefits to fill more of the gaps in your coverage, like prescription drugs. See Chart of Ten Standardized Medigap Plans A through J in Appendix A. Do any Medigap policies cover prescription drugs? Yes. Plans H and I offer the "basic" prescription drug benefit. Plan J offers the "extended" prescription drug benefit (see below). Plans H and I Basic Prescription Drug Benefit After you pay... $250 per year deductible The plan pays... 50% of prescription drug costs up to a maximum of $1,250 per year Plan J Extended Prescription Drug Benefit After you pay... $250 per year deductible The plan pays... 50% of prescription drug costs up to a maximum of $3,000 per year What is a "high deductible option" and how does it affect my costs? Insurance companies may offer a "high deductible option" on Plans F and J. If you choose this option, you must pay a $1,530 deductible for the year 2000 before the plan pays anything. This is an increase for all high deductible plans that were bought before 2000. This amount can increase each year. High deductible option policies often cost less but, if you get sick, your out-of-pocket costs will be higher and you may not be able to change plans. In addition to the $1,530 deductible that you must pay for the high deductible option on plans F and J, you also must pay deductibles for prescription drugs ($250 per year for Plan J) and foreign travel emergency ($250 per year for Plans F and J). How can I get information on Medigap policies in my state? You can get information about Medigap policies in your state by calling: Your State Insurance Department to find out what Medigap polices are available in your state and which companies sell them; or Your State Health Insurance Assistance Program to get free counseling to help you decide which policy is best for you You also can use a computer to find information on and compare Medigap policies offered in your state. Look on the Internet at www.medicare.gov and click on "Medigap Compare." This website has information on: Which Medigap policies are sold in your state. How to shop for a Medigap policy. What the policies must cover. How insurance companies decide what to charge you for a Medigap policy premium. Your Medigap rights and protections. Are There Programs to Help Low-Income Beneficiaries? There are several programs that help pay Medicare costs. Through the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program and the Qualifying Individuals (QI1 and QI2) programs, low-income people with Medicare may receive state assistance to pay Medicare premiums, deductibles or coinsurance. For more information, contact your local Department of Social Services, State Health Insurance Assistance Program or Area Agency on Aging. People struggling to pay for Medicare may qualify for benefits through the following programs: Qualified Medicare Beneficiary (QMB) Specified, Low-income Medicare Beneficiary (SLMB) Qualifying Individuals 1 (QI-1) These federal government programs help people on fixed incomes pay for Medicare coverage. They are administered by the Health Care Financing Administration (HCFA). You can apply for these benefits at your local Medicaid office. What You Should Know To qualify for QMB, SLMB or QI-1, individuals or couples must meet certain income and resources guidelines. QMB may cover the cost of Medicare premiums, deductibles and coinsurance for Medicare Part A (hospital insurance) beneficiaries whose monthly income is less than: $716 for an individual $958 for a couple SLMB benefits may be available to individuals or couples whose income is too high to qualify for QMB. SLMB will pay the monthly Medicare Part B premium of $45.50, but only for those whose monthly income is less than: $855 for an individual $1,145 for a couple The bottom line: QMB helps cover medicare costs for low-income persons If income is too high for SLMB, QI-1 may help pay the monthly Medicare Part B premium for some whose monthly income is less than: $960 for an individual $1,286 for a couple However, funds for the QI-1 program are limited. Applications are approved on a first-come, first-served basis until the funds for a given year run out. For all three programs discussed above, savings must be less than: $4,000 for an individual $6,000 for a couple For More Information If you think you might be eligible for one of these programs, apply at your county´s Department of Human or Social Services. Their phone number is in the blue government section of your local phone directory. You can also call the Health Care Financing Administration´s hotline at 1-800-633-4227. What if Medicare Says No? If Medicare denies a claim for payment or services, you can ask Medicare to reconsider its decision. When you receive a written denial, you'll receive information on how to appeal as well Before you start your appeal, call your State Health Insurance Assistance Program for free information and assistance. In hospital cases, if you think you're being asked to leave the hospital early, contact your state's Peer Review Organization (PRO) for an initial review. If the PRO agrees that you don't need to stay in the hospital, it will tell you how to appeal further. 1. DENIAL NOTICE You get a notice of denial of payment or service, and you disagree with it. (Always request a written denial. You will get instructions on how to appeal.) 2. RECONSIDERATION Send the denial notice back to Medicare with a "please review" note. Try to add supporting information from your doctor. 3. FAIR HEARING (PART B ONLY) Request a fair hearing if you don't agree with the Reconsideration decision. At least $100 must be in dispute. 4. ADMINISTRATIVE LAW JUDGE (ALJ) HEARING At least $100 must be in dispute , (Part A). At least $500 must be in dispute (Part B) 5. DEPARTMENT APPEALS BOARD (DAB) You can appeal to the DAB if you disagree with the ALJ. 6. APPEAL TO FEDERAL COURT To appeal to federal court: At least $1,000 must be in dispute. 7. Final Decision Resources Telephone and Web Resources For more free information on your Medicare rights, options and the Medicare program: 1-800-MEDICARE (1-800-633-4227) The Medicare hotline can provide general information about Medicare and detailed comparisons of the Medicare health plan options in your community. These options include Original Medicare and, where available, Medicare managed care plans, such as Medicare HMOs. You also can get information about the quality of care and member satisfaction in Medicare managed care plans, such as Medicare HMOs. Medicare This official U.S. Government site for Medicare provides up-to-date information about Medicare, Medicare health plans, wellness, fraud and abuse, nursing homes and consumer publications. View the Medicare handbook, Medicare and You and the 1999 Guide to Health Insurance for People with Medicare or order by calling 1-800-MEDICARE (1-800-633-4227). URL: http://www.medicare.gov Medicare Compare Medicare Compare provides the costs and benefits of the Medicare health plan options in your community, which you can compare side by side. This site also contains information about the quality of care and member satisfaction in Medicare managed care plans, such as Medicare HMOs. URL: http://www.medicare.gov/comparison/ Medicare Important Contacts Find the important Medicare contacts in your state and local community. These contacts include your State Health Insurance Assistance Program (SHIP) and Peer Review Organization. URL: http://www.medicare.gov/Contacts/Overview.asp Medicare Rights Center The Medicare Rights Center, a national, not-for-profit organization, represents the interests of Medicare beneficiaries and provides a free counseling service to Medicare beneficiaries. Order a wide range of consumer publications covering Medicare basics, Medicare HMOs, Medicare appeal rights, home and hospice benefits and supplemental insurance by calling 212-869-3850, Ext. 10. URL: http://www.medicarerights.org Agency for Health Care Policy and Research (AHCPR) AHCPR is the lead federal agency supporting research designed to improve the quality of health care, reduce its cost and broaden access to essential services. View AHCPR's publication, Your Guide to Choosing Quality Health Care or order by calling 1-800-358-9295. URL: http://www.ahcpr.gov National Committee on Quality Assurance (NCQA) NCQA, a private, not-for-profit organization, assesses and reports on the quality of managed care plans. Check online to find out if the HMO you are in or considering has been accredited by NCQA. You also can call NCQA at 1-888-275-7585 for this information. Order NCQA's publication, Choosing Quality: Finding the Health Care Plan That's Right For You by using the online order form or by calling 1-800-839-6487. URL: http://www.ncqa.org/Pages/Main/consumers.html State Insurance Departments Links to your state insurance department Websites, if available, from the National Association of Insurance Commissioners (NAIC) Website. NAIC also provides a list of the health contacts in state insurance departments. State insurance departments are responsible for licensing and regulating insurance companies doing business in their state and approving their Medigap policies. They often have consumer information and can help with complaints. URL: http://www.naic.org/consumer/state/commlist.html Department of Labor, Pension and Welfare Benefits Administration(PWBA) PWBA is responsible for administering and enforcing standards to protect the health and pension benefits of many workers, retirees and dependents. Its Consumer Information on Health Plans Website provides information and publications on how life and work events, such as retiring, affect employees' health benefit choices. Several brochures can be viewed on-line or ordered by calling 1-800-998-7542. URL: http://www.dol.gov/dol/pwba/public/health.html Endnotes Official Government site for Medicare www.medicare.gov 2000 Guide to Health Insurance for People with Medicare, HCFA, Department of Health and Human Services, Washington, DC, 2000. American Association of Retired Persons www.aarp.org