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If you need to consult with an attorney about issues on Medicare, please contact the Erie County Bar Association's Lawyer Referral Service.

Medicare

Medicare is a social health insurance program for people age 65 or older, for certain people with disabilities who are under 65, and for people of any age who have permanent kidney failure. Certain qualified individuals may also buy into the program regardless of age. If you are receiving Social Security or railroad retirement benefits, you are automatically enrolled in Medicare when you turn 65. All others should contact Social Security at least three months before their 65th birthday. If you are under 65, you may be eligible for Medicare if you have been a Social Security disability beneficiary for 25 consecutive months. Persons with permanent kidney failure may be eligible for Medicare at any age if they receive maintenance dialysis or a kidney transplant, and if they are covered under their own work record or the work record of a spouse or parent.

Part A of Medicare is hospital insurance that pays for inpatient and critical access care in a hospital up to 150 days, subject to applicable deductibles and staggered increasing coinsurance for the first 60 days, a daily coinsurance for days 61 to 90, and then a daily coinsurance for days 91 to 150. Most people do not pay a premium for Part A because they or their spouse paid applicable Medicare taxes while working. For those that are not eligible for premium-free Part A, the monthly premium in 2018 is up to $422.00. Part A pays for skilled nursing care following three days of hospitalization as an in-patient, up to 100 days with no deductible but is subject to a daily coinsurance after the first 20 days of stay in the facility. Part A pays for approved home health care, with unlimited number of visits by professional caregivers, and durable medical equipment, with co-insurance. Part A provides free approved hospice care for terminally ill people for an indefinite period.

Part B of Medicare is medical insurance that covers doctor's services, clinical lab services, ambulance transportation, outpatient hospital care, bone mass measurement, x-rays, diagnostic and preventive services, and supplies not covered by Part A. If you signed up for Part B when you first became eligible, your standard monthly premium is $134.00 in 2018. An annual deductible must be met before Medicare Part B begins paying for covered services, and this deductible is $183.00 in 2018. Part B covers influenza immunization once a year, pneumococcal pneumonia vaccination once in a lifetime, and hepatitis B vaccination for those of high or medium risk for the disease. Part B beneficiaries with diabetes are eligible for diabetic infusion pumps, blood glucose monitors, testing strips, lancets, and self-management education and training with a doctor's certification. Also, Part B female beneficiaries are covered for screening pap smear and pelvic exam, including a clinical breast exam, every 24 months for all women with Part B and once every 12 months for high risk Part B beneficiaries. Part B female beneficiaries age 40 and older are covered once annually for a mammogram screening. Part B male beneficiaries age 50 and older are covered for a digital rectal exam and a prostate specific antigen (PSA) test every year. Part B covers beneficiaries age 50 and older for a fecal occult blood test once a year, and a flexible screening sigmoidoscopy every four years (depending on relevant risk factors determined by your physician). Screening colonoscopies are covered every 24 months for beneficiaries at high risk for colorectal cancer.

Effective January 1, 2006, Part D was the new prescription drug program through Medicare whereby Medicare beneficiaries entitled to benefits under Part A or enrolled in Part B may elect coverage for prescription drug benefits.  Part D is insurance and private companies provide the coverage for the prescription drugs through approved plans. A monthly premium is assessed to the beneficiary and the Part D beneficiary is responsible for a deductible and a portion of the costs of the prescription drugs. For a plan to qualify under Part D, all drug plans must provide coverage at least as good as the "standard coverage" established by Medicare. In 2006, a Part D beneficiary will be responsible for the monthly premium of their selected plan and an annual deductible of $405.00 for the prescriptions. After the first $405.00, a Part D beneficiary will be responsible for the following costs: 25% of the annual drug costs from $405 to $3,750. After you exceed this amount, Medicare will cover 65% for brand-name drugs (you pay 35%) and 56% for generic drugs (you pay 44%). 

Generally speaking, Medicare will not pay for custodial care, nursing home care, dental care and dentures, routine checkups and tests, most immunization shots, routine foot care, most eyeglasses and hearing aids, personal comfort items, and services provided outside of the United States.

Under the traditional fee-for-service system, Medicare pays a percentage of your hospital, doctor, and other health care expenses. You are responsible for certain deductibles and coinsurance payments that are adjusted on an annual basis. Under a managed care program, Medicare contracts with a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO) which must provide all covered hospital and medical services. As stated previously, you must enroll in Part B and pay the monthly premium. The HMO or PPO receives a monthly payment from Medicare. In addition, the HMO or PPO may charge you a monthly premium and a small copayment each time you use the service.

To enroll for Medicare or for more information, contact Social Security at 717 State St., Highmark Building, Fifth Floor, Erie, PA 16501. Their telephone number is 800-772-1213.  2/18