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Medicare - FAQs:
Medicare Part B helps cover medically-necessary services like doctors’ services and tests, outpatient care, home health services, durable medical equipment, and other medical services. Part B also covers some preventive services. Look at your Medicare card to find out if you have Part B.
The basic medically-necessary services covered include:
- Abdominal Aortic Aneurysm Screening
- Ambulance Services
- Blood
- Bone Mass Measurement (Bone Density)
- Cardiac Rehabilitation
- Cardiovascular Screenings
- Chiropractic Services (limited)
- Clinical Laboratory Services
- Clinical Research Studies
- Colorectal Cancer Screenings
- Defibrillator (Implantable Automatic)
- Diabetes Screenings
- Diabetes Self-Management Training
- Diabetes Supplies
- Doctor Services
- Durable Medical Equipment (like walkers)
- EKG Screening
- Emergency Department Services
- Eyeglasses (limited)
- Federally-Qualified Health Center Services
- Flu shots
- Foot Exams and Treatment (Diabetes-related)
- Glaucoma Tests
- Hearing and Balance Exams
- Hepatitis B Shots
- HIV Screening
- Home Health Services
- Kidney Dialysis Services and Supplies
- Kidney Disease Education Services
- Mammograms (screening)
- Medical Nutrition Therapy Services
- Mental Health Care (outpatient)
- Non-doctor Services
- Occupational Therapy
- Outpatient Medical and Surgical Services and Supplies
- Pap Tests and Pelvic Exams (includes clinical breast exam)
- Physical Exams
- Physical Therapy
- Pneumococcal Shot
- Prescription Drugs (limited)
- Prostate Cancer Screenings
- Prosthetic/Orthotic Items
- Pulmonary Rehabilitation
- Rural Health Clinic Services
- Second Surgical Opinions
- Smoking Cessation (counseling to stop smoking)
- Speech-Language Pathology Services
- Surgical Dressing Services
- Telehealth
- Tests (other than lab tests)
- Transplants and Immunosuppressive Drugs
In your 2011 Medicare & You booklet, see pages 30–44 for a detailed description of common Part B-covered services listed above. Medicare may cover some services and tests more often than the timeframes listed in the charts if needed to diagnose a condition.
To find out if Medicare covers a service not on this list, visit www.medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
To find a doctor that accepts Medicare and Medicaid payments, you may want to visit the Centers For Medicare and Medicaid Services' Physician Compare. You can search by State, County, City, Zip Code, and doctor's name. This tool will provide you with a list of physicians in the specialty and geographic area you specify, along with detailed physician profiles, maps and driving directions.
Hospital Compare (Centers for Medicare & Medicaid Services) provides information about Medicare participating hospitals that compare quality measures of Heart Attack (AMI), Heart Failure Care, and Pneumonia Care.
There are many other directories that will help you find health professionals, services, and facilities, some of which may serve Medicare or Medicaid payments. A complete list of these directories is available at: http://www.nlm.nih.gov/medlineplus/directories.html
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non?emergency or non-urgent care). These rules can change each year.
Learn More with this Medicare.gov information:
- Medicare Advantage (Part C)
- Your Guide to Medicare Private Fee-for-Service Plans (PDF - 28 pages)
- Your Guide to Medicare's Preferred Provider Organization (PPO) Plans (PDF - 32 pages)
- Your Guide to Medicare Special Needs Plans (PDF- 20 pages)
- Use Medicare's Information on Quality to Help You Compare Plans (PDF - 5 pages
The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their web site at www.socialsecurity.gov.
The Medicare.gov Web site also has a tool to help you determine if you are eligibile for Medicare and when you can enroll. It is called the Medicare Eligibility Tool.
IF YOU ALREADY RECEIVE BENEFITS FROM SOCIAL SECURITY:
If you already get benefits from Social Security or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month you turn age 65. You will not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If your 65th birthday is February 20, 2010, your Medicare effective date would be February 1, 2010. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2010, your Medicare effective date would be January 1, 2010.)
IF YOU ARE NOT GETTING SOCIAL SECURITY BENEFITS:
If you are not getting Social Security benefits, you can apply for retirement benefits online. If you would like to file for Medicare only, you can apply by calling 1-800-772-1213.
IF YOU ARE UNDER AGE 65 AND DISABLED:
If you are under age 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you will be automatically entitled to Medicare Part A and Part B beginning the 25th month of disability benefit entitlement. You will not need to do anything to enroll in Medicare. Your Medicare card will be mailed to you about 3 months before your Medicare entitlement date. (Note: If you are under age 65 and have Lou Gehrig's disease (ALS), you get your Medicare benefits the first month you get disability benefits from Social Security or the Railroad Retirement Board.) For more information about enrollment, call the Social Security Administration at 1-800-772-1213 or visit the Social Security web site. See also Social Security's FAQ: When should I sign up for Medicare benefits? which explains the enrollment process.
For more information, see Medicare.gov
Generally, we advise people to file for Medicare benefits 3 months before age 65. Remember, Medicare benefits can begin no earlier than age 65. If you are already receiving Social Security, you will automatically be enrolled in Medicare Parts A and B without an additional application. However, because you must pay a premium for Part B coverage, you have the option of turning it down. You will receive a Medicare card about two months before age 65. (Note: Residents of Puerto Rico or foreign countries will not receive Part B automatically. They must elect this benefit.)
If you would like to file for Medicare only, you can apply by calling 1-800-772-1213. Our representatives there can make an appointment for you at any convenient Social Security office and advise you what to bring with you. When you apply for Medicare, we often also take an application for monthly benefits. You can apply for retirement benefits online.
Medicare will pay for the flu shot once every flu season. In some cases, this may mean twice in one year. For example, if you received a flu shot in January for one flu season, Medicare will cover another flu vaccine the following October for another flu season.
You pay nothing for the flu shot if the doctor or other health care provider accepts the Medicare-approved amount as full payment for giving the shot.
The following is a listing of the Medicare premium, deductible, and coinsurance rates that will be in effect in 2012:
Medicare Premiums for 2012:
Part A: (Hospital Insurance) Premium
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Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
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The Part A premium is $248.00 per month for people having 30-39 quarters of Medicare-covered employment.
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The Part A premium is $451.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium
The standard Medicare Part B monthly premium will be $99.90 in 2012, a $15.50 decrease over the 2011 premium of $115.40. However, most Medicare beneficiaries were held harmless in 2011 and paid $96.40 per month. The 2012 premium represents a $3.50 increase for them.
In 2012, Social Security monthly payments to enrollees will increase by 3.6 percent. The dollar increase in benefit checks is expected to be large enough on average to cover the increase in the Part B premium of $3.50 that most beneficiaries will experience. For those who were paying the standard premium of $115.40, their benefits checks will only increase.
As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income. Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2012 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.
In addition to the standard Part B premium, affected beneficiaries must pay an income-related monthly adjustment amount. These income-related amounts were phased-in over three years, beginning in 2007. About 4 percent of current Part B enrollees are expected to be subject to these higher premium amounts.
For additional details, see our FAQ titled: "2012 Part B Premium Amounts for Persons with Higher Income Levels".
Medicare Deductible and Coinsurance Amounts for 2012:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2012 = $1,156) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
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A total of $1,156 for a hospital stay of 1-60 days.
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$289 per day for days 61-90 of a hospital stay.
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$578 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
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All costs for each day beyond 150 days
Skilled Nursing Facility Coinsurance
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$144.50 per day for days 21 through 100 each benefit period.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)
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$140.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $140.00 deductible.)
Additional information about the Medicare premiums, deductibles, and coinsurance rates for 2012 is available in the October 27, 2011 Fact Sheet titled, "Medicare Premiums and Deductibles for 2012" on the www.cms.gov website.
To report suspected Medicare fraud, call toll free 1-800-HHS-TIPS (1-800-447-8477).
HHS has joined with the Department of Justice and AARP to launch a national initiative against fraud, waste, and abuse in the Medicare program. The campaign,"Who Pays? You Pay," is aimed at both waste and at criminal fraud and abuse against the Medicare program.
Learn More:
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Medicare Fraud Overview (Medicare.gov)
Medicare is a Federal health insurance program for people 65 years or older, certain people with disabilities, and people with end-stage renal disease (ESRD). Medicare has two parts -- Part A , which is hospital insurance, and Part B, which is medical insurance. For information on Medicare, visit the Web site at http://www.medicare.gov or call toll free, 1-800-MEDICARE (1-800-633-4227).
Medicare Prescription Drug Coverage: Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information about this program, visit: http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-d.aspx.
Medicaid is a jointly-funded, Federal-State health insurance program that helps many people who can't afford medical care pay for some or all of their medical bills. Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy and stay healthy. Medicaid is available only to people with limited income. You must meet certain requirements to be eligible for Medicaid. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.
Learn More: http://www.cms.hhs.gov/home/medicaid.asp
The State Children's Health Insurance Program (SCHIP), created in 1997, expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. Through the national "Insure Kids Now" initiative, each state has its own SCHIP program that makes health insurance coverage available to children in working families. For more information, visit www.insurekidsnow.gov or call toll free 1-877-KIDS-NOW (1.877.543.7669). This Web site andtoll free number also provide information on Medicaid.
Medicare Part D is Prescription Drug Coverage. Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information about this program, please visit: http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-d.aspx.
You may apply for this benefit on-line at the Social Security site: https://secure.ssa.gov/apps6z/i1020/main.html
Check the answers to Frequently Asked Questions about Medicare Part D.
Or call for live help:
1-800-MEDICARE
(1-800-633-4227)
TTY: 1-877-486-2048 24 hours a day, 7 days a week!
Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:
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You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
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You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
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You or your spouse had Medicare-covered government employment.
To find out if you are eligible, go the Medicare.gov eligibility tool.
If you (or your spouse) did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:
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You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (Note: If you have Lou Gehrig's disease, your Medicare benefits begin the first month you get disability benefits.)
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You are a kidney dialysis or kidney transplant patient.
While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.
Prescription Drug Coverage
Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information, you may wish to visit the Prescription Drug Coverage site at: http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-d.aspx.
How to get a replacement:
You can now request a replacement red, white, and blue Medicare card online on Social Security's (SSA) web site. Your card will be mailed within 30 days to the address SSA has on record.
This service can be accessed during the following hours:
Monday-Friday: 5 a.m. until 1 a.m.
Saturday : 5 a.m. until 11 p.m.
Sunday : 8 a.m. until 10 p.m.
Holidays : 5 a.m. until 11 p.m.
To make an online request, you will need the following information:
- Your last (exact) payment amount or the month and year you last received a payment if you have received benefits in the last 12 months.
- Your name as it appears on your most recent Social Security card
- Your Social Security Number
- Your Date of Birth
- Your phone number in case we need to contact you about your request
- Your e-mail address (optional)
You may also need:
- Your Place of Birth
- Your Mother's Maiden Name (to help identify you)
This service can be accessed via the Social Security Administration Web site. If you prefer, or if you are unable to use the online request to obtain a replacement Medicare card, call Social Security's toll-free number, 1-800-772-1213. Their representatives there will be glad to help you. You can also visit a local social security office. For the office closest to you try their Field Office Locator.
Changing your contact information:
To report your new address and request a replacement card at the same time, please call or visit Social Security.
To Contact Social Security in the United States:
- Call our toll-free number 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778. Representatives are available Monday through Friday between 7 a.m. and 7 p.m.
- Call or visit your local Social Security office. You can get directions and a map to your local Social Security Office by visiting the Local Office Locator.
Outside the United States, call or visit:
- Your nearest Social Security office,
- The closest U.S. Embassy or consulate, or
- The Veterans Affairs Regional Office (VARO) in the Philippines.
If you are a health care provider who bills for services, you probably need an NPI, National Provider Identifier. If you bill Medicare for services, you definitely need an NPI! Getting an NPI is easy and free. The first step is to get your NPI. Once you obtain your NPI, it is estimated that it will take 120 days to do the remaining work to use it. This includes working on your internal billing systems, coordinating with billing services, vendors, and clearinghouses, testing with payers.
As outlined in the Federal Regulation, (The Health Insurance Portability and Accountability Act of 1996 (HIPAA)) you must also share your NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes. If you delay applying for your NPI, you risk your cash flow and that of your health care partners as well.
Learn More:
You will find guidance regarding the Prescription Drugs Medicare Part D program at:
http://www.cms.gov/PrescriptionDrugCovContra/12_PartDManuals.asp
Medicare.gov offers a site that you can put in information and receive detiled information that describes coverage and options under Medicare. Detailed information is available on:
- coverage under Medicare,
- the amount you need to pay,
- which part of Medicare pays for the test, service or item,
- the Medicare contact for your area, and
- important notes.
To enter your information and learn about coverage, see: http://www.medicare.gov/Coverage/Home.asp
If you have questions regarding Medicare benefits, then your answer may available be at one of the resources listed below:
- www.medicare.gov,
- Medicare Beneficiaries Frequently Asked Questions,
- or call 1-800-MEDICARE.
Medicare Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.
Cost: Most people don't have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while they were working. If you (or your spouse) didn't pay Medicare taxes while you worked and you are age 65 or older, you may be able to buy Part A.
If you aren't sure if you have Part A, look on your red, white, and blue Medicare card. If you have Part A, "Hospital (Part A)" is printed on your card. You can call Social Security at 1-800-772-1213, or visit your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.
Eligibility: To learn if you are eligible for Medicare, use the Medicare Eligibility Tool.
Also, see Medicare.gov Part A (Hospital Insurance)
Medicare Part B helps cover medical services like doctors' services, outpatient care, and other medical services that Part A doesn't cover. Part B is optional. Part B helps pay for covered medical services and items when they are medically necessary. Part B also covers some preventive services like exams, lab tests, and screening shots to help prevent, find, or manage a medical problem.
Cost: If you have Part B, you pay a Part B premium each month. Most people will pay the standard premium amount. Social Security will contact some people who have to pay more depending on their income. If you don't sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.
For more information about enrolling in Medicare, look in your copy of the "Medicare & You" handbook, call Social Security at 1-800-772-1213, or visit your local Social Security office. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.
Learn More:
