Business Assistant/Business Assistant.iso/legal/guide7_3/lharc6.exe/MEDICARE.TUT

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/* The following is information is distributed by the United
States Social Security Administration concerns Medicare.
As you will note the information refers to 1985. It is to
our understanding the most current available information.*/

   INFORMATION ABOUT MEDICARE

  1.  Introduction
  2.  Hospital Insurance
      Eligibility
  3.  Medical Insurance
      Eligibility
  4.  Hospital Insurance
      Benefits
  5.  Medical Insurance Benefits
  6.  Other Health Insurance

/*SECTION 1 */
          Introduction

Medicare is a Federal health insurance program for people 65 or
older, people of any age with permanent kidney failure, and
certain disabled people. It is administered by the Health Care
Financing Administration. Local Social Security Administration
offices take applications for Medicare, assist beneficiaries in
filing claims, and provide information about the program.

Medicare has two parts; Hospital insurance helps pay for
inpatient hospital care and certain followup care. Medical
insurance helps pay for your doctor's services and many other
medical services and items.

Hospital insurance is financed through part of the Social
Security tax. Voluntary medical insurance is financed from the
monthly premiums paid by people who have enrolled for it and from
general Federal revenues.


Eligibility Requirements
For Hospital Insurance

 1 If You Are Nearing 65
 2 If You Are Disabled
 3 Permanent Kidney Failure


   If You Are Nearing Age 65

You do not have to retire to have hospital insurance at age 65.
But if you plan to keep working, you will have to file an
application in order for your hospital insurance protection to
begin. You should apply at a Social Security office about 3
months before you reach 65.

If you are receiving Social Security or railroad retirement
checks, your hospital insurance will start automatically at 65.
If you are a Federal retiree who is eligible for Medicare on the
basis of Federal employment, you will have to apply for hospital
insurance in order for it to begin at 65. Contact a Social
Security office about 3 months before 65.

If you are not eligible for hospital insurance at 65 you can buy
it. The basic premium is $174 a month in 1985. To buy hospital
insurance you also have to enroll and pay the monthly premium
for medical insurance. You can apply at any Social Security
office.


      If You Are Disabled

If you are under age 65 and disabled, you will have hospital
insurance protection automatically when you have been entitled
to Social Security disability benefits for 24 months.

If you are a widow or a widower between 50 and 65 years old and
you have been disabled at least 2 years but haven't applied for
disability benefits because you are getting other Social Security
benefits, you may be eligible for hospital insurance. Contact a
Social Security office for information.

If you are a Federal employee and you become disabled before 65,
you may be eligible for Medicare on the basis of your Federal
employment. But, because of a 29 month waiting period that will
usually apply, the earliest your hospital insurance protection
could start will be June 1985.  For more information, contact
any Social Security office.

    Permanent Kidney Failure

If you, your spouse, or your dependent child needs kidney
dialysis or a kidney transplant, contact a Social Security office
to apply for Medicare. You can apply by phone, or a
representative can visit you to take an application if you are
unable to visit an office.

If you are eligible for Medicare, your protection will start with
the third month after the month you actually begin maintenance
dialysis treatments. Under certain conditions, your coverage could
start earlier. The people in the Social Security office can tell
you exactly when your protection will begin.


 Medical Insurance Eligibility

  1.  Who Is Eligible
  2.  Who Must Apply
  3.  Initial Enrollment Period

        Who Is Eligible

Almost anyone who is 65 or older or who is eligible for hospital
insurance can enroll for Medicare medical insurance. You don't
need any Social Security or Federal work credits to get medical
insurance.

If you want medical insurance, you pay a monthly premium for this
protection. The basic premium is $15.50 a month in 1985.

Some people are automatically enrolled in medical insurance,
others must apply. See the section entitled "Who Must Apply" for
more details.

         Who Must Apply

If you are receiving Social Security benefits or retirement
benefits under the railroad retirement system, you will be
automatically enrolled for medical insurance, unless you say you
don't want it, at the same time you become entitled to hospital
insurance.

/*Thus you need to inform the Social Security Administration
if you do not require Medicare because you have adequate other
insurance.*/

You will have to apply for medical insurance if you:
  - plan to continue working past age 65;
  - are 65 but aren't eligible for hospital insurance;
  - have a permanent kidney failure;
  - are a disabled widow or widower between 50 and 65 who isn't
getting disability checks;
  - are eligible for Medicare on the basis of Federal employment;
  - live in Puerto Rico or outside the U.S.

Contact your local Social Security office or railroad retirement
office for detailed information about medical insurance
enrollment.


   Initial Enrollment Period

There is a seven month initial enrollment period for medical
insurance. This period begins three months before the month you
first become eligible for medical insurance and ends three months
after that month. For example, if you are eligible for medical
insurance in July, your initial enrollment period starts April 1
and ends October 31.

If you don't take medical insurance during your initial
enrollment period, you can sign up during a general enrollment
period, January 1 through March 31 of each year. But if you
enroll during a general enrollment period, your protection won't
start until the following July and your monthly premium will be
10 percent higher than the basic premium for each 12 month period
you could have been enrolled but were not.

/*There is a penalty for enrolling late, so apply on time!*/

Special rules apply to workers and their spouses age 65 through
69 who have employer group health coverage. See the section
entitled "Other Health Insurance" for more information.

  Hospital Insurance Benefits

  1.  Inpatient Hospital Care
  2.  Skilled Nursing Facility
      Care
  3.  Home Health Care
  4.  Hospice Care

    Inpatient Hospital Care

Medicare hospital insurance can help pay for inpatient hospital
care. Hospital insurance helps pay for up to 90 days in any
participating hospital in each benefit period. In 1985, hospital
insurance pays for all covered services for the first 60 days,
except for the first $400.  For the 61st through the 90th day,
hospital insurance pays for all covered services except for $100
a day.

If you ever need more than 90 days of hospital care in any
benefit period, you can use some or all of your 60 non-renewable
reserve days. For each reserve day you use, hospital insurance
pays for all covered services except for $200 a day.

Covered services include semiprivate room, all meals, regular
nursing services, operating and recovery room costs, hospital
costs for anesthesia services, intensive care and coronary care,
drugs, lab tests, X-rays, medical supplies and appliances,
rehabilitation services, and preparatory services related to
kidney transplant surgery.


 Skilled Nursing Facility Care

If you need inpatient skilled nursing or rehabilitation services
after a hospital stay and meet certain other conditions, hospital
insurance helps pay for up to 100 days in a participating skilled
nursing facility in each benefit period. In 1985, hospital
insurance pays for all covered services for the first 20 days and
all but $50 a day for up to 80 more days.

Covered services include semiprivate room, all meals, regular
nursing services, rehabilitation services, drugs, medical
supplies, and appliances.


        Home Health Care

If you are confined to your home and meet certain other
conditions, hospital insurance can pay the full approved cost of
home health visits from a participating home health agency. There
is no limit to the number of covered visits you can have.

Covered services include part-time skilled nursing care, physical
therapy, and speech therapy. If you need one or more of those
services, hospital insurance also covers part-time services of
home health aides, occupational therapy, medical social services,
and medical supplies and equipment.

          Hospice Care

Under certain conditions, hospital insurance can help pay for
hospice care for terminally ill beneficiaries if the care is
provided by a Medicare-certified hospice. Special benefit periods
apply to hospice care. Hospital insurance can pay for a maximum of
two 90-day periods and one 30-day period.

Covered services include doctor's services, nursing services,
medical appliances and supplies including outpatient drugs for
pain relief, home health aide and homemaker services, short-term
inpatient care including respite care, and counseling.

Hospital insurance pays part of the cost of outpatient drugs and
inpatient respite care.  For all other covered services, hospital
insurance pays the full cost.

   Medical Insurance Benefits

  1.  Annual Deductible

  2.  Doctor's Services

  3.  Other Medical Services

       Annual Deductible

Medicare medical insurance helps pay for your doctors' services
and a variety of other medical services and supplies that are
not covered by hospital insurance. Most of the services needed
by people with permanent kidney failure are covered only by
medical insurance.

Each year, as soon as you meet the annual medical insurance
deductible, medical insurance generally will pay 80 percent of
the approved charges for covered services you receive during
the rest of the year.  In 1985, the annual deductible is $75.

       Doctors' Services

Medical insurance covers doctors' services no matter where you
receive them in the United States. Covered doctors' services
include surgical services, diagnostic tests and X-rays that are
part of your treatment, medical supplies furnished in a doctor's
office, services of the office nurse, and drugs which are
administered as part of your treatment and cannot be
self-administered.

     Other Medical Services

Medical insurance covers outpatient hospital services you receive
for diagnosis and treatment, such as care in an emergency room
or outpatient clinic of a hospital. Medical insurance can also
cover an unlimited number of home health visits if all required
conditions are met.

Under certain conditions or limitations, medical insurance covers
other medical services and supplies. Some examples are: ambulance
transportation; home dialysis equipment,  supplies, and periodic
support services; independent laboratory tests; oral surgery;
outpatient physical therapy and speech pathology services; and
X-rays and radiation treatments.


    Other Medical Insurance

  1.  What Medicare Won't Pay
  2.  Other Health Plans
  3.  Buying Supplemental
      insurance
  4.  Employer Health Plans

  What Medicare Won't Pay For

Medicare provides basic protection against the high cost of
illness, but it will not pay all of your health care expenses.
Some of the services and supplies Medicare cannot pay for are:
custodial care, such as help with bathing, eating, and taking
medicine; dentures and routine dental care; eyeglasses, hearing
aids, and examinations to prescribe or fit them; personal comfort
items such as a phone or TV in your hospital room; prescription
drugs and patent medicines; and routine physical checkups and
private room; and routine related tests.

       Other Health Plans

Many private health insurance companies point out that their
policies for people who have Medicare are designed only to
supplement Medicare. They recommend that their policyholders
sign up for Medicare medical insurance to have full protection.

If you have other health insurance, it may not pay for some of
the services that are covered by Medicare medical insurance.
You should get in touch with your insurer or agent to discuss
your health insurance needs in relation to Medicare protection.
This is particularly important if you have dependents who are
covered under your present policy.

If you have health care protection from the Veterans
Administration, the Indian Health Service, a Federal employees'
health plan, or a State medical assistance program, the people
there can probably help you to decide whether it is to your
advantage to have Medicare medical insurance.  Be sure not to
cancel any health insurance you now have for your own protection
until the month your Medicare coverage begins.

 Buying Supplemental Insurance

If you are thinking about buying private insurance to supplement
Medicare, please examine the policy carefully. Make sure it does
not simply duplicate your Medicare coverage. If you want help in
deciding whether to buy private supplemental insurance, ask at
any Social Security office for the pamphlet, "Guide To Health
Insurance For People With Medicare".  This free pamphlet
describes the various types of supplemental insurance available.

  Employer Group Health Plans

Employers with 20 or more employees are required to offer workers
and their spouses age 65 through 69 the same health benefits that
are offered to younger workers.

If you work past 65 and accept your employer's health plan,
Medicare will be the secondary health insurance payer.  If you
reject your employer's health plan, Medicare will be the primary
health insurance payer.

Also, if you are 65-69 and continue to work (or are a spouse
65-69) and have an employer health plan, you can wait to enroll
in Medicare medical insurance during a special enrollment period.
You won't have to pay the 10 percent premium surcharge for late
enrollment, if you meet certain requirements.

For more information about these special rules, contact your
employer.

If you are entitled to Medicare solely on the basis of permanent
kidney failure and you are covered by an employer group health
plan, Medicare will be the secondary payer for an initial period
of up to 12 months. At the end of the 12-month period, Medicare
becomes the primary payer.