Income:
No income test.

Assets:
No assets test.

Age:
Must be 65 or older, or disabled, or suffering from permanent kidney failure, or in need of kidney transplant.

Disability:
Hospital Insurance (HI): Disabled beneficiaries of Disability Insurance (workers under 65, disabled widows and widowers 50-65, and children 18 or over who became disabled before the age of 22) are eligible, after they have been on the Disability Insurance benefit rolls for 2 years.

Medicare coverage was expanded for disability beneficiaries who work. Effective October 1, 2000, HI coverage is extended for 4 1/2 years beyond the previous limit of 39 months (for a total of 93 months) under the Ticket to Work legislation.

Supplementary Medical Insurance (SMI): Disabled beneficiaries are eligible for SMI in the same manner as eligible persons 65 and over (see Prior Contribution, below).
Chronic kidney disease: A person with chronic kidney disease requiring regular dialysis or a kidney transplant is eligible providing some other conditions are met (See Other Eligibility Conditions, below).

Presence of Spouse:
Not a condition.

Presence of Children:
Not a condition.

Prior Contribution:
Hospital Insurance (HI) is financed primarily through a payroll tax levied on workers and their employers but also through federal general revenues. Employers and employees each pay a tax of 1.45% on all earnings. The self-employed pay a single tax of 2.9% on all earnings.

For premium free Hospital Insurance, an applicant or worker on whom applicant was or is financially dependent must have worked and paid Medicare taxes for at least 10 years. Or he or she must be age 65 and receiving retirement benefits from Social Security: Old Age Insurance or the Railroad Retirement Board; or he/she must be 65 and eligible receive Social Security retirement benefits or Railroad benefits but has not yet filed for them; or worker or spouse had Medicare-covered government employment and are age 65.

The Hospital Insurance premium for those who are not eligible for premium-free Medicare is $443 per month. The HI premium is $222 for individuals having 30 or more Quarters of Coverage but not the required 40 (10 years).

Supplementary Medical Insurance (SMI) for outpatient care has a monthly premium. As a general rule, a person should enroll in Medicare SMI when first eligible for full coverage with Medicare. Delaying enrollment in SMI could entail a penalty of 10% of the SMI premium for each year which passes. But, if the applicant or his/her spouse is still working after turning 65, or became eligible for Medicare based on disability, and health insurance is provided through that job, the applicant can delay signing up for Medicare without having to pay a penalty if the company the applicant or his/her spouse works for continues to provide health insurance.

Effective January 1, 2009, the SMI monthly premium is $96.40 for most Medicare beneficiaries. This is the premium that is automatically deducted monthly from Social Security checks. It is likely to change every January. The SMI annual deductible is $135 for 2009.

**Effective January 2007, adjustment in the amount of Part B premium is required for individuals with higher incomes. Individuals with MAGI (modified adjusted gross income) of $80,000+ and couples (married, filing jointly) with $160,00+ will have higher monthly Part B premiums. MAGI is the AGI plus tax exempt interest income as shown on line 8b of the IRS form 1040. This info will be provided by IRS to Social Security. These higher premiums range from $134.90 to $308.30

Exhaustion of Benefits From Other Programs:
Medicare pays remaining covered costs after payments paid under private liability policies, including automobile insurance. Medicare is the secondary payer for employed individuals and their spouses aged 65-69 who are covered by employer group health plans. It is also the secondary payer after a public program such as Workers’ Compensation.

If patient is entitled to Medicare because of permanent kidney failure and has employer-provided group health coverage, Medicare will be the secondary payer for the first 30 months of Medicare HI eligibility. At the end of the 30-month period, Medicare becomes the primary payer. Note: When a patient enrolls in Medicare based on ESRD (permanent kidney failure) and is on dialysis, Medicare coverage usually starts dialysis treatments.

Type:
Medicare offers choices among original Medicare, Medicare Advantage plans or contracting with a health care provider. All reimburse providers for part of the costs of health care.

Original Medicare:
Original Medicare, also called traditional Medicare, is a pay-per-visit or fee-for-service arrangement. This is the Medicare choice with which beneficiaries may be the most familiar. Original Medicare applies with any doctor, hospital or health care provider that accepts Medicare. Payments are made for each service that is rendered. Original Medicare is available nationwide. It has two parts, Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B).

Medicare Advantage Plans: Medicare Advantage Plans are one of the health plan choices of the Medicare program. They include HMOs and PPOs as noted below:

Medicare Managed Care Plans (HMO's): In most of these plans, an individual can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. This is called the plan’s “network.” An individual may also have to choose a primary care doctor and get referrals to see a specialist. He/she may pay lower co-payments and get extra benefits, such as coverage for extra days in the hospital.

Medicare Preferred Provider Organization Plans (PPO's): In most of these plans, an individual may use doctors, specialists, and hospitals on the plan’s list (network). An individual can go to doctors, specialists, or hospitals not on the plan’s list, but it may cost extra. He/she does not need referrals to see doctors, specialists, or go to hospitals that are not part of the plan’s network. An individual may pay lower co-payments and get extra benefits, such as coverage for extra days in the hospital.

Medicare Private Fee-for-Service Plans: If an individual joins one of these plans, he/she can go to any doctor or hospital that accepts the terms of the plan’s payment. The private company, rather than the Medicare program, decides how much it will pay and how much the individual pays for the services received. He/she may get extra benefits, like coverage for extra days in the hospital.

Medicare Specialty Plans: These plans, if available, provide more focused health care for specific people. If an individual joins one of these plans, he/she will get Medicare health care as well as more focused care to manage a specific disease or condition.

Medicare Private Contracting:
One provision of the federal Balanced Budget Act of 1997 allows doctors to have
"private contracts" with Medicare beneficiaries. In this case, patients become responsible for the full cost of services normally covered by Medicare. The
law did not change regarding services that are not covered by Medicare. The Act
simply adds a third way to pay for Medicare-covered services.

These three ways are:
(1) Assignment: A doctor can still accept Medicare assignment. He or she then must
submit a bill directly to Medicare and be paid at the Medicare payment rate. The beneficiary (and/or his or her Medigap policy) pays only the copayment and any deductible.

(2) Not Assigned: A doctor can still be a Medicare provider but not accept assignment.
The doctor may bill the beneficiary for up to 15 percent above the approved rate
for procedures covered by Medicare. The beneficiary (and/or his or her Medigap policy) is responsible for the copayment, the deductible and the doctor's additional bill.

(3) Private Contract: The law now allows doctors to "opt out" of Medicare
and have private contracts with beneficiaries for services that otherwise would
be covered by Medicare. The beneficiary must pay the full cost for these services
at a rate agreed between the beneficiary and the doctor.

A private contract is a written contract between a Medicare beneficiary and a doctor.
The doctor "opts out" of Medicare for all services normally covered by Medicare. Medicare beneficiaries who sign private contracts with one or more doctors, however, can still obtain Medicare-reimbursed services from other providers who have not signed such a contract. (In this summary, we are using "services" to mean all "items and services" and "doctor" to mean "physician or other practitioner." Other practitioners include a licensed physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist and clinical social worker).

In this contract, the Medicare beneficiary agrees to give up Medicare payment for services provided by the doctor, even though those services normally are covered by Medicare AND pay the doctor, out of his/her own pocket, for the agreed upon (full) price of care. The limits that Medicare and New York State law impose on doctors' charges will not apply.

Hospital Insurance (Part A):
For a complete list of services and coverage see www.medicare.gov, call 1-800-Medicare or request various Medicare publications for different subjects.

Deductibles and co-payments: A beneficiary of HI must pay a deductible of $992 in 2007 for the first 60 days of each benefit period or “spell of illness.” A benefit period or “spell of illness” begins when a Medicare beneficiary enters a hospital and uses HI; a benefit period ends when the beneficiary has been out of the hospital or facility providing skilled nursing care or rehabilitative services for 60 days in a row (including the day of discharge).

For all days from the 61st-90th days of hospitalization, the individual must pay a co-payment of $248 per day. For all days after the 90th day, persons covered by HI may choose to use up days from a lifetime reserve of 60 days. While using these reserve days, beneficiaries must pay co-payments of $496 per day. Daily cost-sharing payments are based on the year in which the hospital stay occurred. Beneficiary pays all costs beyond 150 days.

(b) Skilled nursing: Facility benefits: Semiprivate room, meals, skilled nursing and rehabilitative services and other services and supplies. There is no deductible and no coinsurance for the first 20 days; a coinsurance payment of $124 per day for days 21-100; and no coverage beyond the 100th day in the benefit period.

Note: Medicare does not cover long term care.

c) Home health services: Limited to reasonable and necessary intermittent skilled nursing care, physical therapy, occupational 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. There are no deductibles or co-payments for home health services. Payment of 20% of approved amount for durable medical equipment (such as a wheelchair, hospital beds, oxygen) is required.

(d) Hospice care: Pain and symptom relief and supportive services for the care of a terminal illness. Home care is provided. Also covered are necessary inpatient care and a variety of services otherwise not covered by Medicare. Patient pays limited costs for outpatient drugs and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).

(e) Blood: From a hospital or skilled nursing facility during a covered stay, there is a deductible of the cost of the first three pints.

For a complete list of services and coverage see www.medicare.gov, call 1-800-Medicare or request various Medicare publications for different subjects.

(a) Physician and surgeon services: Doctors' services, inpatient and outpatient medical and surgical services and supplies, physical, occupational and speech therapy, diagnostic tests, and durable medical equipment (DME). There is a $131 deductible paid once per year and co-payments of 20% of approved amount after the deductible, except in the outpatient setting where co-payments vary according to the service; 50% for most outpatient mental health services; 20% for all outpatient physical, occupational and speech-language services.

(b) Clinical laboratory service: Blood tests, urinalysis, and some other laboratory services are covered and the beneficiary pays nothing for Medicare-approved services.

c) Home health care: Limited to reasonable and necessary intermittent skilled care, home health aide services, durable medical equipment (DME) and supplies and other services. Subscribers pay nothing for services and 20 percent of approved amount for durable medical equipment (DME).

(d) Outpatient hospital services: Services for the diagnosis or treatment of an illness or injury. There is a coinsurance or fixed co-payment amount that may vary according to service.

(e) Blood: As an outpatient, or as part of a Part B covered service. There is a deductible of the cost of the first three pints plus 20% of the cost of the approved amount for additional pints after the deductible.

Basic Rule: Foot exams and treatment may be covered if the patient has diabetes-related nerve damage and certain other conditions. Medicare does not pay for: a) treatment of flat feet; b) treatment of subluxation (or structural misalignment of joints) of the foot; or, c) routine foot care. Routine care includes cutting or removal of corns, calluses, trimming of nails, routine hygiene and any other service performed in absence of localized illness, injury or symptoms involving the feet.

Medicare considers the following items as "non-routine" foot care or otherwise pays for their diagnosis and treatment: a) ulcers, wounds or infections of the feet; b) warts; c) fungal (mycotic) infection of the toenail if there is clinical evidence of mycosis and medical documentation that the patient has marked limitation of ambulation requiring active treatment of the foot, or in the case of a nonambulatory patient the condition is likely to result in significant complications in absence of such treatment; d) services incident to, at the same time as or as a necessary, integral part of a primary covered procedure performed on the foot; and e) services part of initial diagnostic services (regardless of resulting diagnosis) in connection with a specific symptom or complaint that might arise from a condition whose treatment would be covered.

Beneficiaries with Diabetes: In addition to the same non-routine foot care for all beneficiaries, Medicare pays for foot care for a) diabetes, and b) diagnosis of sensory neuropathy. Medicare pays for treatment of superficial wounds, cutting or removal of corns and calluses and trimming of toenails in persons with diabetes.

Preventive Services and Screening Benefits:
For a complete list of services and coverage see www.medicare.gov, call 1-800-Medicare or request various Medicare publications for different subjects.

Screening mammogram: One baseline mammogram for women between the ages of 35 and 39. Once per year for all women with Medicare, age 40 and older. The required payment is 20% of the Medicare approved amount with no SMI deductible.

Pap smear and pelvic examination: For all women with Medicare, once every 2 years and once per year if there is a high risk for cervical or vaginal cancer or if of childbearing age and had an abnormal Pap smear in the preceding 3 years. There are no coinsurance and no SMI deductible for the Pap smear (clinical laboratory charge). For doctor’s services and all other exams, the subscriber 20% of the Medicare approved amount with no SMI deductible. These diagnostic services include a clinical breast exam.

Glaucoma screening: For Medicare beneficiaries with diabetes, a family history of glaucoma or African-Americans age 50 and over. Requires payment of 20 % of the Medicare approved amount after the annual SMI deductible.

Diabetes monitoring: Helps pay for glucose monitors, test strips, lancets, and self-management training for all Medicare beneficiaries with diabetes (insulin users and non-users). Entails payment of 20% of the Medicare approved amount after the annual SMI deductible

Bone mass measurement: Varies according to health status and includes certain Medicare beneficiaries at risk for losing bone mass. A 20% payment of the Medicare approved amount after the annual SMI deductible is required.

Vaccinations: All Medicare beneficiaries are entitled to: a flu shot once every year; a pneumonia shot as prescribed by doctor; Hepatitis B shot if at medium to high risk for hepatitis. There are no coinsurance and no SMI deductible for flu and pneumonia shots if the doctor accepts assignment. For Hepatitis B shots, beneficiaries pay 20% payment of the Medicare approved amount after the SMI deductible.

Prostate cancer screening: All male Medicare beneficiaries over age 50 are entitled to a digital rectal examination once every year and Prostate Specific Antigen (PSA) test once every year for all men with Medicare age 50 and older. Generally, there is a 20% payment of the Medicare approved amount after the yearly SMI deductible. There are no coinsurance and no SMI deductible for the PSA test.

Colorectal cancer screening: All Medicare beneficiaries age 50 or older are entitled to a Fecal Occult Blood test once every year and a Flexible Sigmoidoscopy once every 4 years. Regardless of age, Medicare beneficiaries are entitled to a colonoscopy once every 2 years if at high risk for cancer of the colon and once every 10 years or within 4 years of screening a Flexible Sigmoidoscopy if not at high risk. Doctors can substitute a Barium Enema for a Sigmoidoscopy or Colonoscopy. There are no coinsurance and no SMI deductible for the Fecal Occult Blood test. For all other tests beneficiaries are required to pay 20% payment of the Medicare approved amount after the annual SMI deductible (25% if performed in an ambulatory surgical center or hospital outpatient department).

Physical exams (routine): If Medicare Part B begins on or after January 1, 2005, Medicare will cover a one-time preventive physical exam within the first six months that an individual has Medicare Part B.

• acupuncture;
• deductibles;
• coinsurance, or co-payments for health care services;
• dental care and dentures (with only a few exceptions);
• cosmetic surgery;
• custodial care (help with bathing, dressing, using the bathroom and eating) at home or in a nursing home;
• health care received while traveling outside of the United States (except in limited cases);
• hearing aids and hearing exams;
• long-term care, such as most nursing home care;
• orthopedic shoes (with only a few exceptions);
• outpatient prescription drugs (with only a few exceptions);
• routine foot care (with only a few exceptions);
• routine eye care and most eyeglasses;
• routine or yearly physical exams;
• screening tests (with some exceptions);
• shots (vaccinations);
• some diabetic supplies (like syringes or insulin unless it is used with an insulin pump).

Where and How to Apply:
To enroll in Medicare, Part A and/or Part B, contact the Social Security Administration at 1-800-772-1213.

An individual must enroll for Supplementary Medical Insurance during an initial enrollment period beginning 3 months before attaining age 65 and ending 3 months after age 65. In addition, there is a general enrollment period each year from January through March. If an individual does not enroll during the initial enrollment period, he/she may be required to pay a premium penalty.


Financing:
Hospital Insurance:
Except for the small number of enrollees who are not eligible for Hospital Insurance (HI) and choose to pay for it, HI is financed by a Federal payroll tax, divided evenly between employers and employees and paid fully by the self-employed. Employers and employees each pay 1.45% on all earnings; self-employed persons pay 2.9% on all earnings.

Supplementary Medical Insurance:
Supplemental Medical Insurance (SMI) is financed by general revenues and beneficiary premiums. Currently, general revenues pay for approximately 75 percent of the cost of SMI, and the monthly premiums pay for the other 25 percent.

Premiums:
HI is generally provided automatically, and free of premiums, to persons age 65 or over who are eligible for Social Security or Railroad Retirement benefits, whether they have claimed these monthly cash benefits or not. A premium of $410 per month is paid by individuals who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare covered employment. There is a premium surcharge for late enrollment. The HI premium is $226 for those individuals having 30 but less than 40 quarters of Medicare covered employment. Late enrollees with more than 30 but less than 40 credits must pay a surcharge.

All citizens (and certain legal aliens) age 65 or over, and all disabled persons entitled to coverage under HI, are eligible to enroll in the SMI program on a voluntary basis by payment of a monthly premium. Almost all persons entitled to HI choose to enroll in SMI. The SMI premium for most individuals for 2007 is $93.50 per month.

In 2009, approximately 5 percent of Medicare Part B enrollees with higher incomes will pay a higher Part B premium based on their income. The income-related Part B premium for 2009 will be from $134.90 to 308.30, depending on the extent to which an individuals beneficiary's income exceeds $85,000 (or married couple's income exceeds $170,000), with the highest premium rates only paid by less than 1 percent of beneficiaries whose incomes are over $213,000 (or $426,000 for a married couple). A beneficiary who pays the highest income-related premium in 2009 would pay $3,699.60 per year in Part B premiums.

Prescription Drug Coverage (Part D):

Medicare offers prescription drug coverage for everyone with medicare. This is called "Part D." This coverage may help lower prescription drug costs and help protect against higher costs in the future. It can give individuals greater access to drugs that they can use to prevent complications of diseases and stay well. If individuals join a Medicare drug plan, they usually pay a monthly premium. Part D is optional. If they decide not to enroll in a Medicare drug plan when first eligible, they may pay a penalty if they subsequently decide to enroll. These plans are run by insurance companies and other private companies approved by Medicare.

There are two ways to get Medicare prescription drug coverage:

1) Join a Medicare Prescription Drug Plan that adds drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans and Medicare Medical Savings Account Plans.

2) Join a Medicare plan (like an HMO or PPO) that includes prescription drug coverage as part of the plan. You get all of your Medicare coverage through these plans, including prescription drugs.

Most drug plans charge a monthly premium that varies by plan. Individuals pay this in addition to the Part B premium. Some drug plans charge no premium. If individuals have limited income and resources, they may get extra help to cover prescription drugs for little or no cost. Costs will vary depending on which drugs are used, which Medicare drug plan is chosen, and whether individuals get extra help paying Part D costs.

Standard Coverage (the minimum coverage drug plans must provide).

Effective January 1, 2007, for covered drugs individuals will pay a monthly premium (varies depending on the plan, but most costs are in the mid-$30 range). They also pay the first $265 per year for prescriptions. This is called the deductible.

After individuals pay the $265 yearly deductible, they pay

• 25% of yearly drug costs from $265 to $2,400, and the plan pays the other 75% of these costs, then

• 100% of the next $3,051.25 in drug costs, then

• a coinsurance amount (e.g., 5%of the drug cost) or a copayment (e.g., $2.15 or $5.35 for each prescription) for the rest of the calendar year after you have spent $3,850 out-of-pocket. The plan pays the rest.

Administration:
By the Centers for Medicare & Medicaid Services (CMS) (formerly called the Health Care Financing Administration or HCFA) of the United States Department of Health and Human Services. Much of the day-to-day work of reviewing claims and making payments is done by intermediaries (for HI) and carriers (for SMI). These are generally commercial insurers or Blue Cross Blue Shield plans.


Procedures for Appeal:
In response to claims, Medicare beneficiaries receive a Medicare Summary Notice (MSN). A disagreement with any claims decision on the MSN may be appealed. The appeal must be requested within 6 months from the date on the MSN.

To request an appeal: circle the item(s) in dispute and explain the disagreement; sign and provide telephone contact number; and send the notice, or a copy, to the address in the "Customer Service Information."   If Medicare does not pay for an item or service a person has been given or has not provided an item or service he/she thinks should be received, a request may be made to review the initial Medicare decision again.

The amount of time for filing a request for a re-determination of an HI claim has been increased to 120 days. The previous time was 60 days.  The time allowed for filing a request for a review of an SMI claim has been reduced to 120 days. However, carriers may extend the deadline 60 days if the patient, provider or supplier requests additional time in order to gather necessary supporting medical records.

The amount in controversy for requesting an Administrative Law Judge (ALJ) hearing must be at least $100 for SMI claims and for initial determinations of hospital claims made by Quality Improvement Organizations (QIOs). If the ALJ rules against the individual, he/she may appeal to the Department Appeals Board (DAB) and, finally, if not satisfied with the results of the appeals process, the individual has the right to appeal to Federal court within 60 days of an unfavorable DAB decision if the amount involved is over $1000.

Medicare Advantage Plan
If an individual is enrolled in a Medicare Advantage Plan, he/she has the right to a fast-track appeals process. He/she can get a quick review when receiving services from a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility. The individual will get a notice from the provider or plan that will tell him/her how to ask for an appeal if he/she believes that services are ending too soon. The individual will be able to obtain a quick review of this decision, with independent doctors looking at the case and deciding if services need to continue. An individual may have additional rights if he/she is in the hospital or a skilled nursing facility, or if home health care ends. People with Medicare enrolled in the Original Medicare Plan are expected to get fast-track appeal rights during 2005.

Additional Resources:
The Medicare Web site http://www.medicare.gov has information about appeals and grievances as well as appeals forms. Every Medicare Advantage Plan is required by law to provide its enrollees with information on accessing the appeals system.

Help for Some Low-Income Medicare Beneficiaries Medicare Savings Programs (help from Medicaid paying Medicare premiums) What is this program?

States are required to provide Medicaid to "qualified Medicare beneficiaries (QMBs)" for purposes of paying Medicare cost-sharing expenses (i.e., Medicare premiums, deductibles, and coinsurance amounts).

States have programs for people with limited income and resources that pay Medicare premiums and, in some cases, may also pay Medicare Part A and part B deductibles and coinsurance. These programs help millions of people with Medicare save money each year.

Who qualifies for this program?

• Individuals must have Medicare Part A. The Medicare Savings Program may pay Part A or Part B premiums.

• They must have resources of $4,000 or less, or a married couple with resources of $6,000 or less. Resources include things like money in a checking or savings account, stocks, and bonds, but don't include things like a house or car.

• They must have a monthly income of less than $1,123, or a married couple with a monthly income of less than $1,505. Income limits will increase slightly in 2007.

States are responsible for making QMB determinations. QMB eligibility begins with the month after the month the State makes the QMB determination.

Specified Low Income Medicare Beneficiary (SLMB) Program
Medicare beneficiaries with incomes between 100% and 120% of the Federal Poverty Level are eligible for the SLMB. Under 2005 Poverty Guidelines, individuals with monthly income up to $1000 and couples with income up to $1,340 are eligible. This program pays for a beneficiary's Medicare SMI premium.

Qualified Individual 1 (QI-1) Program
Medicare beneficiaries with incomes between 120% and 135% of the Federal Poverty Level are eligible for the Qualified Individual 1 (QI-1) Program. Under poverty guidelines for 2006, individuals with monthly income up to $1,123 and couples with income up to $1,505 are eligible. There is no limit on assets. This program pays for a beneficiary's Medicare SMI premium as well as deductibles and co-payments.

How To Apply for QMB, SLMB, and QI-1
Individuals who may be qualified can apply at their local Social Service Department's Medicaid Assistance Unit. For more information the website is: http://hiicap.state.ny.us/medicare/localdss.htm.

Applications for the SLMB and QI-1 programs can be taken on a short application form. For the QMB program, a full Medicaid application is used.

The following resources are considered during the screening process for QMB and SLMB:

• cash on hand
• checking accounts
• savings accounts
• certificate of mutual funds
• savings bonds
• IRA
• Keogh
• 401-K or deferred compensation accounts
• trusts
• real estate including income and non-income producing property. A home in which the applicant(s) resides is not considered a resource and is not counted in the eligibility determination process.