Omaha ElderCare Resource Handbook

Medicare

Medicare is federal health insurance for people aged 65 and over, people under 65 with certain disabilities, and people with end-stage renal disease.  Medicare is divided into four parts:  Part A is hospital insurance.  Part B is medical insurance.  Part C, known as Medicare Advantage, provides the option to choose from different health care plans.  Part D provides the option to choose from different prescription drug plans.  Medicare does not cover everything, nor does it always cover the full amount.

There are 2 main ways to get your Medicare coverage – Original Medicare or a Medicare Advantage Plan.

  • If you decide to go with Original Medicare, you decide if you need prescription drug coverage (Part D) and/or a Medicare  Supplemental Insurance (Medigap) policy.
  • If you decide to use a Medicare Advantage Plan (Part C), that plan combines Part A and Part B and most cover Part D or give you the option to add prescription drug coverage.

Medicare & You is a booklet with information on Medicare benefits, rights and protections, lists of available health and drug plans, and answers to the most frequently asked questions.  This handbook as well as other available publications are revised yearly and available in both English and Spanish.  You may obtain a copy by calling the Medicare office or read them online at www.medicare.gov.

With questions or for information, contact:

Medicare
www.medicare.gov
877-486-2048 (TTY)
800-MEDICARE (1-800-633-4227)
Social Security Administration:
www.ssa.gov
800-325-0778 (TTY)
800-772-1213
SHIIP (Senior Health Insurance Information Program)
Nebraska
www.doi.nebraska.gov/shiip 
800-234-7119
402-444-6617
SHIIP (Senior Health Insurance Information Program)
Iowa
www.therightcalliowa.gov
800-351-4664

In this section, we will cover the basics of Medicare Parts A-D as well as some general things to look for in a Medigap policy.

Medicare 2016 Part A

Part A (Hospital Insurance) helps pay for care in hospitals and nursing facilities, hospice care and some home health.  Medicare Part A, along with Part B, is often referred to as Original Medicare.

Part A is premium-free for most people because of Medicare taxes paid while working.  If you are not eligible for premium-free Part A, the 2016 premium is up to $411/month depending on your income.  In most cases, if you choose to buy Part A, you must also buy Part B.   Copayments, coinsurance, or deductibles may apply for each of the Medicare Part A covered services.  If you are in a Medicare Advantage Plan or have other insurance, your costs may be different.

If you are already receiving benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically be enrolled in Medicare Parts A & B the first day of the month you turn 65.  Otherwise, you may enroll from 3 months prior to your birth month until 3 months after your birth month by calling    Social Security or by applying online at www.socialsecurity.gov/retirement.  If you do not sign up when first eligible, you can sign up between January 1st-March 31st each year for coverage starting July 1st.  You may receive a late enrollment penalty.  If you did not sign up for Medicare because you were covered under another group health plan, you may sign up during a Special Enrollment Period.

Some covered services are listed in the chart on the following page.  Services are listed by benefit period.  It is important to remember that staying overnight in the hospital does not necessarily mean it is an inpatient stay.

For more information on approved Medicare Part A services and to find current carriers for Nebraska, contact the Medicare office at 1-800-633-4227 or go online at www.medicare.gov.

Medicare (Part A): Hospital Insurance-Covered Services Per Benefit Period(1)
Service Benefit Medicare Pays(2) You Pay(2)
Hospital Stays
Semi-private room, meals, general nursing, drugs and other hospital services & necessary supplies; includes mental health or acute care.(3)
Days 1-60 All but $1288 $1288
Days 61-90 Amt over $322/day $322/day
Days 91-150(4) Amt over $644/day $644/day
Days 150+ Nothing All Cost
Post-Hospital Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing & rehabilitative services. Medicare-approved facility, must be within 30 days after discharge of at least a 3-day hospital stay.(3)(5)
Days 1-20 All Cost Nothing
Days 21-100 Amt over $161/day $161/day
Days 100+ Nothing All Cost
Home Health Services
Skilled care, therapies & DME ordered by a doctor and provided by a Medicare-certified agency. Individual must be homebound.
Unlimited as long as doctor ordered and Medicare-approved. 100% of approved amount. 80% of approved durable medical equipment. Nothing for services if approved amount. 20% of approved amount of durable medical equipment.
Hospice Care
Drugs for pain relief & symptom management; medical, nursing, social & grief services.(5)
Unlimited; Doctor must certify you are expected to live 6 months or less. All  hospice care.  All but $0-$5 copay for outpatient drugs. 95% of inpatient respite care(5). 0% for hospice care. $0-$5 copay for outpatient drugs. 5% of inpatient respite care.
Blood
If not from a blood bank or donated(6).
Unlimited After first 3 pints First 3 pints
(1)  A benefit period begins on the first day you are admitted as an inpatient in a hospital or skilled nursing facility and ends after you have been out of the hospital or skilled nursing facility for 60 days in a row.  There is no limit to the number of benefit periods.
(2)  These figures are for 2016 and are subject to change each year.
(3)  If religious beliefs prohibit conventional medical care and you qualify for hospital or skilled nursing facility care, Medicare may cover non-religious, non-medical items and services in a non-medical health care institution.
(4)  Lifetime Reserve Days give you a total of an extra 60 days that can be used when hospitalized for over 90 days.  They are non-renewable.  Inpatient mental health care in a  psychiatric hospital is limited to 190 days in a lifetime.
(5)  Medicare and private insurance will not pay for most nursing home care.  Medicare does not cover housing when you get hospice care in your home or another facility.  Medicare may cover some inpatient respite care for hospice patients.
(6)  If from a blood bank or donated, there is no charge in Part A.  Once the blood deductible is met, it is met for both Part A & Part B.

Medicare 2016 Part B

Part B (Medical Insurance) helps pay for medically necessary doctor’s services, outpatient care, home health, durable medical equipment and some preventive services.   Medicare Part B, along with Part A, is often referred to as Original Medicare.

The standard 2016 premium is $121.80/month.  Individuals who paid $104.90/month in 2015 will keep that rate for 2016.  The premium can be up to $389.80/month for those with higher incomes.  It is deductible from Social Security, Railroad or Civil Service Retirement.  If the Part B deductible ($166 in 2016) applies, you must pay all costs until you meet the yearly deductible.  At this point, Medicare begins to pay its share.  After your deductible is met, you typically pay 20% of the Medicare-approved amount for medically necessary services and nothing for preventive services if the provider accepts the Medicare rate.   There is no yearly limit to what you pay out-of-pocket.  If you are in a Medicare Advantage Plan or have other insurance, your costs may be different.

If you are already receiving benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically be enrolled in Medicare Parts A & B the first day of the month you turn 65.  Otherwise, you may enroll from 3 months prior to your birth month until 3 months after your birth month by calling Social Security or by applying online at www.socialsecurity.gov/retirement.  If you are automatically enrolled in Part B and do not want to enroll yet, follow the instructions that come with the card and send it back.  If you do not sign up when first eligible, you can sign up between January 1st-March 31st each year for coverage starting July 1st.  You may receive a late enrollment penalty.  If you did not sign up for Medicare because you were covered under another group health plan, you may sign up during a Special Enrollment Period.

Some covered services are listed in the chart on the following page. For further information about Medicare Part B covered services, you can view Your Medicare Benefits at www.medicare.gov or order a copy by calling 1-800-633-4227.

To find current carriers for Nebraska, contact the Medicare office at 1-800-633-4227 or go online at www.medicare.gov.

Medicare (Part B): Medical Insurance-Covered Services Per Benefit Period
You pay a $166 (1) yearly deductible for Part B-covered services or items.(2)
Service(3) Benefit Medicare Pays(1) You Pay(1)(2)(4)
Medical Services
Doctor and surgical services & supplies, therapies, and preventive care.
Unlimited if medically necessary 80% of approved amount. 100% of most preventive care(3) 20% of approved amount. Nothing for most preventive care(3)
Mental Health
Diagnosis and outpatient treatment.(5)
Unlimited if approved 80% of approved amount 20% of approved amount
Clinical Laboratory Services
Blood tests, urinalysis, etc.
Unlimited if medically necessary 100% Nothing
Durable Medical Equipment (DME)
O2 supplies, wheelchairs, hospital beds, etc. from a Medicare-approved supplier.
Unlimited if medically necessary 80% of approved amount 20% of approved amount
Home Health Services
Intermittent skilled care, therapy & aides from a Medicare-certified agency. Must be homebound.
Unlimited if medically necessary 100% of approved amount. Nothing for services
Outpatient Hospital Services
Diagnostic & treatment services.
Unlimited if medically necessary 80% of approved amount
(after copayment)
20% of approved amount & hospital copayment which varies by service
Blood
As an outpatient or part of a Part B covered service; if not from a blood bank or donated.(6)
Unlimited None of first 3 pints; all but copayment for any additional First 3 pints & copayment for any additional
(1) These figures are for 2016 and are subject to change each year.
(2) Once you have paid the $166 deductible for covered services, the Part B deductible does not apply to any further services you receive the rest of the year.
(3) The above gives a general idea of covered services.  Contact Medicare for a full listing.  Some preventive services are covered at no cost to you.
(4) You pay for charges higher than the amount approved by Medicare unless the doctor or supplier agrees to accept Medicare’s approved amount as the total charge for services.
(5) Inpatient mental health services are covered under Part A hospital stays.
(6) If from a blood bank or donated, there is a processing copayment in Medicare Part B.  Once the blood deductible is met, it is met for both Part A and Part B.

Medicare Part C

Instead of getting your coverage through Original Medicare, you can choose Medicare Part C, commonly known as Medicare Advantage.  These are Medicare-approved plans obtained through private health insurance companies.  They cover all services offered by Part A and Part B and often offer other benefits such as vision, hearing, dental and wellness depending on the plan.  Most offer prescription drug (Part D) coverage.  You may join a Medicare Prescription Drug Plan if it does not.  Hospice is still covered under Part B.  You pay the Medicare Part B premium and usually an additional premium for added benefits.

There are different types of Medicare Advantage Plans including (but not limited to) HMO plans and MSA Plans.  MSA Plans combine high deductible Medicare Advantage Plans with a Medical Savings Account (MSA).  Medicare pays a fixed amount each month to companies offering Medicare Advantage Plans.  Each plan can charge different out-of-pocket costs and have different rules for obtaining services.

Comparisons of Medicare Advantage Plans available in Nebraska and Iowa can be found using the Medicare Plan Finder at www.medicare.gov/find-a-plan.  Call the specific plans you are interested in to find out more about the type of plan as well as specific rules, costs and benefits to make sure they meet your needs.  You may also call SHIIP at 1-800-234-7119 in Nebraska or 800-351-4664 in Iowa for more information about individual plans.

If you are turning 65, you may enroll in a Medicare Advantage plan from 3 months prior to your birth month until 3 months after your birth month.  If you already have a Medicare Advantage Plan and wish to change it, you may do so between October 15th and December 7th each year for coverage beginning January 1st of the following year. You may enroll in the plan on the Medicare Plan Finder’s site or on the individual plan’s site, by completing a paper enrollment form, by calling the plan directly or by calling 1-800-633-4227.  Once you join a plan, you will be automatically disenrolled from any old plans.  If you join a Medicare Advantage Plan, your Medigap policy will not work.

Medicare Part D

Medicare Part D is a voluntary prescription drug insurance program.  They are stand-alone drug plans offered by private insurance companies.  Persons enrolled in Original Medicare are eligible for a Medicare Part D Prescription Drug Plan (PDP) that offers only prescription drug coverage.  Those who opt for a Medicare Advantage Plan (Part C) are eligible for a Medicare Advantage Prescription Drug Plan (MA-PD) that offers both prescription drug and other health coverage.

There are different PDP and MA-PD options to choose from in Nebraska and Iowa.  Things to consider when deciding on a prescription drug plan that best benefits you include:

  • Drugs covered by that plan
  • Pharmacies available with that plan
  • Annual deductibles
  • Monthly premiums & copayments
  • Possible future needs

Comparisons of prescription drug plans available in Nebraska and Iowa can be found using the Medicare Plan Finder at www.medicare.gov/find-a-plan.  Costs may vary by the specific drug plan you choose, your geographic location and your income.  If you have limited income or resources, you may qualify for extra help paying your drug costs.

If you are turning 65, you may enroll in a Medicare drug plan from 3 months prior to your birth month until 3 months after your birth month.  If you already have a Medicare drug plan and wish to change it, you may do so between October 15th and December 7th each year for coverage beginning January 1st of the following year.  If you do not join a Medicare prescription drug plan when you are first eligible and do not have other creditable prescription drug coverage, you may owe a late penalty when joining.  You may enroll in the drug plan on the Medicare Plan Finder’s site or on the individual plan’s site, by completing a paper enrollment form, by calling the plan directly or by calling 1-800-633-4227.  Once you join a plan, you will be automatically disenrolled from any old plans.  If your Medicare Advantage Plan already includes prescription drug coverage and you join a separate Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

Medicare Supplemental Insurance

For extra benefits, you may purchase a Medicare Supplemental Insurance Policy, called Medigap.  Medigap is sold by private companies to fill the gaps in the Medicare Part A and Part B plan coverages including copayments, coinsurance and deductibles.  You must have both parts A & B to be eligible.  You cannot use a Medigap policy with a Medicare Advantage Plan.  Medicare pays its share of health care costs before the Medigap policy pays.

There are ten Medigap policies to choose from and they are standardized among insurance companies.  Medigap policies must follow federal and state law and they only work with the Original Medicare Plan.  You pay the insurance company a monthly premium in addition to your Part B premium.  Premiums may vary among insurance companies although coverage should not.  Purchasing a Medigap plan allows you to go to any doctor or hospital that accepts Medicare.  You and your spouse must purchase separate plans in order to both be covered.

Medicare SELECT is a type of Medigap policy that may require you to use doctors and hospitals within the carrier’s network in order for you to be eligible for full benefits.

You may enroll in a Medigap policy starting when you enroll in Medicare Part B and enrollment lasts for 6 months.  During this time, companies cannot turn you down due to health reasons, but they may after the enrollment period is over.  It is important to compare policies as there is a wide divergence among them.  Comparisons of Medigap plans can be found using the Medicare Plan Finder at www.medicare.gov/find-a-plan.

Choosing a Medigap Policy:  A Guide to Health Insurance for People with Medicare is a guide for purchasing and using Medigap Insurance as well as understanding other kinds of health insurance available.  For more information on Medicare Supplemental Insurance Policies or to obtain a copy of the guide, contact:

Medicare
www.medicare.gov
1-800-MEDICARE (1-800-633-4227)

Medicare Supplement Policies:  A Guide for Nebraskans outlines the different supplemental insurance policies available in Nebraska.  The Iowa Medicare Supplement & Premium Comparison Guide outlines the different supplemental insurance policies available in Iowa.  Each is revised yearly and available through SHIIP.  For more information or to obtain a copy, contact:

SHIIP (Senior Health Insurance Information Program)
Nebraska
www.doi.nebraska.gov/shiip 
800-234-7119
402-444-6617
SHIIP (Senior Health Insurance Information Program)
Iowa
www.therightcalliowa.gov
800-351-4664

 

Return to the Lincoln ElderCare Handbook