by tcope » Tue Dec 15, 2009 05:46 pm
Medicare is a national health insurance program that was implemented by the US government in the year 1965 as part of the Social Security Act. Since then Medicare has been serving elder Americans, who have reached the age of 65 and have certain disabilities, in getting proper medical care that they need and deserve.
Who qualifies for Medicare?
You will qualify for Medicare under certain conditions. You must be
- 65 years or older or
- Under age 65 but with a specific disability or
- Any age but with terminal-stage renal disease
Who is eligible for Medicare and how to enroll?
Medicare insurance is an entitlement program just like Social Security and anybody who meets the qualifying criteria for Medicare is eligible. The Medicare eligibility criteria are constant throughout America and coverage constant and independent of the state you get treated in.
What are the benefits of Medicare?
Medicare benefits have been divided in 4 main parts by "The Department of Health and Human Services":
- Medicare Part A (Hospital Insurance):
Covers part of inpatient care in hospitals, skilled nursing facility, home health care (if you meet certain conditions) as well as hospice services. Benefit from Medicare Part A can be received beginning from the time you turn 65 if you already receive benefits from Social Security or the Railroad Retirement Board (RRB). If you are under 65 years and have some kind of disability, Part A benefits will be provided after you get disability benefits from Social Security or Railroad Retirement Board for 24 months. You will receive a Medicare card either in the mail 3 months in advance to your 65th birthday or on the 25th month of your disability.
When should you enroll for Medicare Part A?
Medicare Part A or Hospital Insurance can be bought during the period beginning 3 months prior to your 65th birthday and ending 3 months after your 65th birthday. You may also buy this insurance during January 1and March 31 every year. You may even opt for a special enrollment in case you are covered under the group health insurance plan of your spouse's employer or union. - Medicare Part B (Medical Insurance):
Covers services like doctor's service and outpatient care and also a part of the preventive services that helps maintain your health and check some health conditions from worsening.
When should you enroll for Medicare Part B?
If you already get Social Security Benefits or Railroad Retirement Board (RRB) benefits then you will automatically get Part B beginning the day you turn 65. If you are under 65 and disabled, you will be entitled to certain disability benefits from Social Security or RRB for 24 months. - Medicare Part C (Medicare Advantage Plans):
Private insurance companies approved by Medicare manage Part C. Medicare providers have combined hospital care, medical care and also sometimes prescription drug coverage in this plan. Such a plan can, however, charge different co-insurance premiums, co payments or deductibles compared to those charged by the government in Medicare parts A and B.
Part C or which is also popularly known as the Medicare + Choice or "Medicare Advantage" plan requires that you should pay a monthly premium in addition to the fixed premium. Whenever you see a doctor you need to pay a fixed amount but for seeing a specialist you need to pay extra. This plan may be more expensive than the original Medicare plan. - Medicare Part D (Prescription Drug Plan): Covers part of the cost for your prescription drugs. Individual plans vary in cost and the benefits received may also differ. Prescription Drug Plan can be added with the help of private insurance companies. However, if you have Medicare Hospital insurance and Medical Insurance, you will be automatically entitled to the Prescription Drug Plan.
With Medicare Part D you can pay less when buying prescription drugs. Use the Medicare ID card at any drug store and if you have limited income, you may get additional assistance with the costs.
Is there a supplementary plan for Medicare?
Yes there is a Medicare supplement plan for those who feel there are significant gaps or large expenses that is associated with medical cost sharing that can later add up to a Medicare plan. Solutions to cover these gaps have been developed by the collaborative efforts of the Federal and State Governments. You can choose from different levels of coverage.
Is there an alternative to Medicare?
Yes, you can go for a Medicaid plan if you think you can't pay for Medicare right now. Medicaid is available only to families that have a low income and that are eligible for medical aid as mentioned by the federal and state laws.
Medicaid is meant to directly send money to your health care provider. You might just have to pay a co-payment or some fixed amount for any medical service that you take and this amount will depend on the state that you live in. There are certain requirements for Medicaid like:
Medicaid is meant to directly send money to your health care provider. You might just have to pay a co-payment or some fixed amount for any medical service that you take and this amount will depend on the state that you live in. There are certain requirements for Medicaid like:
- Your age
- Whether you are pregnant
- Your income and resources (bank accounts, real property or any other item that can be sold for cash)
- Whether you are disabled (blindness included)
- Whether you are a US citizen or a lawfully admitted immigrant
Medicare has always had a "super lien"... meaning that Medicare could always seek recovery on a payment even if they had not informed the payer of their lien and even if the payer already paid some other party. Now there is Section 111, requiring pretty much everyone to notify Medicare of a payment is being made on an injury claim. That is, insurance companies now need to be pro-active and tell Medicare that they are making a payment beforehand so that Medicare can seek recovery. Medicare no longer needs to learn that a payment is being made... they need to be told.
I have a claim where I have $10,000 to pay toward medical bills. I know the bills were paid by Medicare so I called them to inform. They told me that I needed to report a "claim" and that someone would call me w/in 45 days. I have to file a "claim" when they already know about the claim? Needless to say no one called me so I called back to follow up. Now they tell me that I need to have the person's ID# or they cannot do anything for me. I explain that I simply want to issue then a $10,000 payment and need to have some lien paperwork. They tell me that they cannot discuss it with me due to privacy issues. Huh? If they need authorization to send me a lien then shouldn't _they_ get authorization? Why should I force the injured person to give them autho to send me a bill?
So even though Medicare had all the rights in the world.... and then added more, they _still_ can't figure out how to take money when it's handed to them.
BTW - I was on the phone for 45 minutes to learn this.
I have a claim where I have $10,000 to pay toward medical bills. I know the bills were paid by Medicare so I called them to inform. They told me that I needed to report a "claim" and that someone would call me w/in 45 days. I have to file a "claim" when they already know about the claim? Needless to say no one called me so I called back to follow up. Now they tell me that I need to have the person's ID# or they cannot do anything for me. I explain that I simply want to issue then a $10,000 payment and need to have some lien paperwork. They tell me that they cannot discuss it with me due to privacy issues. Huh? If they need authorization to send me a lien then shouldn't _they_ get authorization? Why should I force the injured person to give them autho to send me a bill?
So even though Medicare had all the rights in the world.... and then added more, they _still_ can't figure out how to take money when it's handed to them.
BTW - I was on the phone for 45 minutes to learn this.
Posted: Wed Dec 16, 2009 11:52 am Post Subject:
That is, insurance companies now need to be pro-active and tell Medicare that they are making a payment beforehand so that Medicare can seek recovery.
I simply don't understand that when it's the carrier who has to inform Medicare about this, then what's the big deal in discussing things with them. If Medicare won't force the claimant to inform them about the payment, then I don't see how they can force you to drag the claimant in between.
Posted: Tue Jan 05, 2010 08:33 am Post Subject:
tcope . . .
You mistake Medicaid for Medicare. What you describe as Medicaid having a "super lien" is known as "asset recovery" and only applies to persons after age 55.
Medicare is health insurance via the Social Security Administration. There is no asset recovery in that program . . . it is all water under the bridge.
Nevertheless, Medicare does have a $74,000,000,000,000+ deficit on schedule for the year 2080.
Posted: Tue Jan 05, 2010 02:17 pm Post Subject:
You mistake Medicaid for Medicare. What you describe as Medicaid having a "super lien" is known as "asset recovery" and only applies to persons after age 55
Why would you think I'm confusing Medicare and Medicade?Medicare is health insurance via the Social Security Administration. There is no asset recovery in that program . . . it is all water under the bridge.
42 U.S.C. § 1395y(b)(2)(B)(ii)
"(B) Conditional payment
(i) Authority to make conditional payment The Secretary may make payment under this subchapter with respect to an item or service if a primary plan described in subparagraph (A)(ii) has not made or cannot reasonably be expected to make payment with respect to such item or service promptly (as determined in accordance with regulations). Any such payment by the Secretary shall be conditioned on reimbursement to the appropriate Trust Fund in accordance with the succeeding provisions of this subsection.
(ii) Repayment required A primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service. A primary plan’s responsibility for such payment may be demonstrated by a judgment, a payment conditioned upon the recipient’s compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan’s insured, or by other means. If reimbursement is not made to the appropriate Trust Fund before the expiration of the 60-day period that begins on the date notice of, or information related to, a primary plan’s responsibility for such payment or other information is received, the Secretary may charge interest (beginning with the date on which the notice or other information is received) on the amount of the reimbursement until reimbursement is made (at a rate determined by the Secretary in accordance with regulations of the Secretary of the Treasury applicable to charges for late payments).
(iii) Action by United States In order to recover payment made under this subchapter for an item or service, the United States may bring an action against any or all entities that are or were required or responsible (directly, as an insurer or self-insurer, as a third-party administrator, as an employer that sponsors or contributes to a group health plan, or large group health plan, or otherwise) to make payment with respect to the same item or service (or any portion thereof) under a primary plan. The United States may, in accordance with paragraph (3)(A) collect double damages against any such entity. In addition, the United States may recover under this clause from any entity that has received payment from a primary plan or from the proceeds of a primary plan’s payment to any entity. The United States may not recover from a third-party administrator under this clause in cases where the third-party administrator would not be able to recover the amount at issue from the employer or group health plan and is not employed by or under contract with the employer or group health plan at the time the action for recovery is initiated by the United States or for whom it provides administrative services due to the insolvency or bankruptcy of the employer or plan.
(iv) Subrogation rights The United States shall be subrogated (to the extent of payment made under this subchapter for such an item or service) to any right under this subsection of an individual or any other entity to payment with respect to such item or service under a primary plan.
(v) Waiver of rights The Secretary may waive (in whole or in part) the provisions of this subparagraph in the case of an individual claim if the Secretary determines that the waiver is in the best interests of the program established under this subchapter.
(vi) Claims-filing period Notwithstanding any other time limits that may exist for filing a claim under an employer group health plan, the United States may seek to recover conditional payments in accordance with this subparagraph where the request for payment is submitted to the entity required or responsible under this subsection to pay with respect to the item or service (or any portion thereof) under a primary plan within the 3-year period beginning on the date on which the item or service was furnished."
I could go on and on quoting the Medicare statutes but I don't see the need. This short quote shows that Medicare _does_ have a right of recovery. This right of recovery also extends to insurance companies that did know, or should have known, that the person had collected under Medicare.
Medicare _can_ apply to others under 65. If the person is disabled for 24 months or longer or has end stage renal disease. The problem for insurance companies is that we cannot know the person's situation and if they qualify for Medicare for whatever reason. It's possible that _anyone_ could qualify. With the new Medicare reporting laws (Section 111) we are required to report SS#s and DOB on everyone we pay out under an injury claim for.
Posted: Wed Jan 06, 2010 05:39 am Post Subject:
Sorry . . . thought you were talking about recovery from an individual. You're addressing recovery from an employer's group plan that was supposed to be primary payer but did not pay, leaving Social Security on the hook as secondary payer.
In the overall scheme of things, this represents a fraction of the total claims Medicare pays, compared to the millions of individual Medicare beneficiaries to which this section of USC does not apply.
It is those individual claims and excessive consumption of medical services (by treating doctors and other providers who are trying to extract maximum reimbursements from Medicare) that are breaking the back of Medicare. And it will only get worse as the Baby Boomers begin to reach Medicare age in another 2-3 years and beyond.
Posted: Thu Jan 13, 2011 12:44 am Post Subject: medicare
Discuss the conditions under which Medicare qualifies as a primary versus secondary payer.
Posted: Thu Jan 13, 2011 06:49 am Post Subject:
If a person age 65 or older works for an employer who offers group health insurance, they may enroll in the group health plan as their primary insurance, which automatically makes Medicare secondary coverage. But that same person can elect NOT to enroll in the employer-sponsored plan (perhaps it is more expensive than the monthly Medicare Part B premium), which automatically makes Medicare the primary coverage -- except in the case of a Workers' Compensation claim. Coverage for work-related injuries and illnesses under Workers' Compensation laws is always primary to Medicare.
Posted: Wed Jan 19, 2011 01:59 am Post Subject: medicare
my motherin law is 78 and receiving ssi and medicare,i noticed that she is getting 1100. per year deducted from her benefits, could that be right
Posted: Thu Jan 20, 2011 06:23 am Post Subject: Part D non-coverage
I am over age 65 and am enrolled in Medicare parts A&B. I elected not to purchase Part D. I have been told, unverified, that California has a state law that prohibits pharmacies form charging persons like myself, Senior Citizens, without Part D coverage more than the Medicare reimbursements plus co-payments for individual drugs.
1. Is the statement correct?
2. How do I ascertain what the maximum allowable charge is for a particular drug?
Posted: Fri Dec 11, 2015 12:30 am Post Subject: Can I Sue?
Question:
My wife and I purchased a Bankers Medicare Supplement Insurance Plan were their agents told us that we would be covered for pre- existing conditions. My wife had a stroke in 11/2012 and I was in a serious car accident in 11/2013. In our multiple discussions with their agents we explained the needs to continue therapy and for yearly medical tests. We were assured that we would be covered. A few months after we started therapy and my wife had all of these tests done we started to receive notices that we were not covered. The agent was supposed to look into it but as of this date they still have not paid anything. Can we sue the agent and the company for payment and misleading us with this policy?
Posted: Wed Dec 23, 2015 06:33 am Post Subject:
You wrote this, and I responded in a different forum. Contact me for immediate assistance.
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