My Patient Guide
Guiding you every step of the way.
Seniors Health
Seniors Health
- Medicare Options
- Original Medicare
- Medigap Insurance
- Medicare Hospital Insurance Program (Part A)
- Hospital Premium
- Benefit Periods
- Inpatient Hospital Deductible/Co-Payments
- Skilled Nursing Facility Care
- Home Health Care
- Hospice Care
- Patients' Rights, HQSI, Quality of Care Complaints
- Hospital Discharge
- Information/Complaints
- Supplementary Medical Insurance Program (Part B)
- Deductible/Limiting Charge
- Transplant Services
- Medicare Prescription Drug Coverage (Part D)
- Prescription Drugs and Other Drug Benefits
- Airway Pressure Device
- Ambulatory Blood Pressure Monitoring
- Chiropractic Coverage
- Eyeglasses
- Foot Care
- Therapeutic Footwear
- Cardiovascular Disease Screening Blood Tests
- Colorectal Cancer Screening
- Diabetes Education
- Diabetes Glucose Monitoring
- Glaucoma Screening
- Bone Mass Measurement
- Pneumococcal Vaccine
- Preventive Physical Examination
- Hepatitis B Vaccine
- Influenza Virus Vaccine
- "Pap Smear" Screening
- Prostate Cancer Screening
- Mammogram
- Medical Nutrition Therapy
- Durable Medical Equipment/Supplies
- Medicare Part B Carrier
- Non-Covered Services Medicare Part A and Part B Services
- Health Maintenance Organization (HMO)
- Preferred-Provider Organization (PPO)
- Provider-Sponsored Organization (PSO)
- Religious Fraternal Benefit Society Plans (RFBS)
- Private Fee-For-Service Plan (PFFS)
- Medicare Special Needs Plan (SNP)
- Medicare Advantage Medical Savings Account (MSA)
- Medicare as Secondary Payer
- Original Medicare Appeals
- Medicare Fraud and Abuse
- Medicare Savings Programs
- Specified Low-Income Medicare Beneficiary (SLMB)
- Qualified Medicare Beneficiary (QMB)
- Qualifying Individual
- Continuing Coverage After Leaving Employment (COBRA)
- Federally Qualified HealthCenters - Medicare (FQHCs)
Medicare
Medicare insurance is generally available to the following: Individuals 65 or older, if they are eligible for, or are receiving, Social Security or Railroad Retirement benefits; individuals (any age) who have received Social Security disability benefits for at least 24 months; individuals (any age) who have permanent kidney failure; and certain government employees whose work has been covered for Medicare purposes. Contact should be made with Social Security (1-800-772-1213, www.ssa.gov) to obtain further information regarding eligibility and enrollment.
Medicare Options - When you are eligible for Medicare, you will be in Original Medicare unless you choose one of the other Medicare options. In New Jersey you have options on how you receive your Medicare coverage: Original Medicare, Medicare Advantage Health Maintenance Organization, Medicare Advantage Preferred Provider Organization – PPO (Point of Service – POS), Medicare Advantage Private Fee-For-Service Plan (PFFS), Medicare Advantage Special Needs Plan (SNP) or Medicare Advantage Medical Saving Account (MSA) Plan. No matter which option you choose, you have Medicare.
Original Medicare - Under Original Medicare beneficiaries receive health benefits under Part A (hospital insurance) and Part B (medical insurance). They generally can go to any doctor, specialist or any hospital that accepts Medicare patients. You must pay a monthly Part B premium which is usually taken out of your monthly retirement payment. You are also responsible for a Part A deductible, and a Part B deductible before Medicare begins to pay. After Medicare pays 80% of the allowed amount for covered medical services, you will also be responsible for a 20% coinsurance.
Medigap is private insurance that is designed to help pay deductibles and coinsurance amounts for Original Medicare - Parts A and B. These policies are also called supplement policies and only work with Original Medicare. You will have to pay a premium for your Medigap policy and you must continue to pay the monthly Part B premium. There are 12 standard Medigap policies and each offers a different combination of benefits that fill different gaps in Original Medicare. The benefits for each plan are the same no matter which company offers them. For a period of six months from the date you are first enrolled in Medicare Part B and are age 65 or older, you have a right to buy the Medigap policy of your choice. Once this Medigap "open enrollment" period ends, you may not be able to buy the policy of your choice. Medigap supplement policies are "guaranteed renewable". The policy cannot be cancelled or non-renewed for any reason except non-payment of premium.
Medicare Hospital Insurance Program (Part A)
Medicare Part A, the premium free Hospital Insurance Program, helps pay for four kinds of medically necessary care: (1) inpatient hospital care; (2) some inpatient care in a skilled nursing facility following a hospital stay; (3) home health care; and (4) hospice care. Part A is free for most people.
Hospital Premium - Premium-free Medicare Hospital Insurance (Part A) is generally available to individuals who are eligible for Medicare. Individuals age 65 and older who are U.S. citizens and residents and who have not worked long enough to qualify for premium-free Part A may buy Medicare coverage. There is a monthly premium and possibly a surcharge for late enrollment. Aliens 65 or over who are US residents and who have been lawfully admitted for permanent residence and have resided in the US for at least five years at the time of filing may also be eligible to purchase both Part A and Part B, or just Part B. If you are not sure you qualify for premium-free Part A, you should contact your local Social Security Office, or call Social Security at 1-800-772-1213 or visit the Medicare website at www.medicare.gov regarding your eligibility to enroll and the amount of the monthly premium for Part A coverage that you would be required to pay.
Benefit Periods - When if you are admitted to a hospital or skilled nursing facility, Medicare Part A pays benefits based on benefit periods. A benefit period begins the first day you receive a Medicare covered service in a hospital or skilled nursing facility (SNF) and ends when you have been out of a hospital or SNF for 60 consecutive days. If you enter a hospital or SNF again after 60 days, a new benefit period begins. All Part A benefits, except for any lifetime reserve days used, are renewed.
Inpatient Hospital Deductible/Co-Payments - Part A pays for all covered services for the first 60 days of inpatient hospital care in a benefit period, except for the Part A deductible. For the 61st-90th day, Part A pays for all covered services except for the per day coinsurance. Every person enrolled in Part A also has a lifetime reserve of 60 days for inpatient hospital care. These days may be used whenever more than 90 days of inpatient hospital care are needed in a benefit period. While reserve days are being used, Part A pays for all covered services except for a per day coinsurance for each "reserve day." Once used, reserve days are not renewable. Deductibles/co-insurance amounts change annually.
Skilled Nursing Facility Care - Medicare Part A can help pay for medically necessary inpatient care in a Medicare-participating skilled nursing facility following a minimum three-day hospital stay. If your stay in a skilled nursing facility is covered by Medicare, Part A helps pay for a maximum of 100 days in each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. Very specific conditions must be met for you to qualify for skilled nursing facility care. Any service that could be safely performed by an average non-medical person (or one's self) without the direct supervision of a licensed health care professional is not covered. In each benefit period, Part A pays for all covered services for the first 20 days you are in a skilled nursing facility. Part A pays for all covered services except for the per day coinsurance for days 21 through 100 which is the responsibility of the beneficiary. If you have questions about what specific conditions must be met for you to qualify for skilled care, please contact Medicare toll-free at 1-800-Medicare (1-800-633-4227).
Home Health Care - Part A pays the approved cost of medically necessary home health visits for homebound beneficiaries following at least a 3-day hospital stay. Coverage includes the intermittent services of a skilled nurse and the services of physical, occupational and speech-language therapists when furnished through a Medicare-certified home health agency. Part A can also cover reasonable and necessary part-time or intermittent home health aide, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) provided under a plan of care established and periodically reviewed by a physician. Part A does not cover full-time nursing care, drugs, meals delivered to your home or homemaker services that are primarily to assist you in meeting personal care or housekeeping needs. Medicare beneficiaries may occasionally leave their home for special non-medical events for brief periods of time without risking termination of their home health benefits coverage. If you have questions about home health care and conditions of coverage, or to order a pamphlet on this topic, call Medicare toll-free at 1-800-Medicare (1-800-633-4227).
Hospice Care - Medicare beneficiaries certified as terminally ill may elect to receive hospice care under Part A instead of regular Medicare. Part A can pay for medical and support services from a Medicare-approved hospice, drugs for symptom control and pain relief, short-term respite care, care in a hospice facility, hospital, or nursing home when necessary, home care and other services not otherwise covered by Medicare. You must meet certain conditions to qualify for this service. If you have questions about this service, or to order a pamphlet on this topic, call Medicare toll-free at 1-800-Medicare (1-800-633-4227).
Patients' Rights, HQSI, Quality of Care Complaints - Medicare requires that hospitals supply a statement of patients' rights to Medicare beneficiaries the day they enter the hospital. In addition, Medicare contracts with Healthcare Quality Strategies, Inc. (HQSI), (formerly PRONJ, the Healthcare Quality Improvement Organization of New Jersey, Inc.,) an independent physician group, to ensure that the beneficiaries receive the best medical care possible. HQSI offers review of appeals of non-coverage during the hospital stay, and responds to written complaints concerning quality of care received. Quality of care complaints must be from Medicare beneficiaries treated in a facility certified by Medicare, and the services received must be services that normally would be covered by Medicare. (NOTE: Complaints about quality of care include treatment as an inpatient/outpatient in a hospital, or provision of services of a skilled nursing facility, home health agency, or ambulatory surgical center).
Hospital Discharge - You have the right to get all of the hospital care that you need, and any follow-up care after you leave the hospital. Before discharge from the hospital, Medicare patients should request a Discharge Plan from their doctor or hospital social worker. This plan will specify the proper post-hospital care and treatment. Medicare patients who feel that the Discharge Plan is unsatisfactory may request to have their case reviewed by Healthcare Quality Strategies, Inc. (HQSI).
Information, Complaints - For more information concerning rights of beneficiaries under Medicare Part A, contact HQSI during business hours at 1-800-624-4557 or 732-238-5570. To file a complaint concerning quality of care, write Healthcare Quality Strategies, Inc., 557 Cranbury Road, Suite 21, East Brunswick, NJ 08816.
Medicare Supplementary Medical Insurance Program (Part B)
Medicare Part B medical insurance helps pay for (1) doctor's services; (2) in/outpatient medical and surgical services and supplies; (3) physical, occupational and speech therapy; (4) diagnostic tests; (5) durable medical equipment; (6) ambulance services; (7) clinical laboratory services (blood tests, urinalysis); (8) home health care when Part A doesn't pay and; (9) other health services and supplies which are not covered by Medicare Hospital Insurance. A monthly premium is charged. Under certain conditions, if you do not enroll for Part B when you are first eligible, you will not be able to enroll until a general enrollment period and you may have to pay a higher monthly premium for delaying enrollment.
Deductible/Limiting Charge - Medicare pays for some of your health care, but not all of it. When you receive health care services, you will have to pay deductibles and coinsurance or copayments. You must pay a deductible before Medicare will pay its share. If a doctor or supplier does not accept the amount Medicare pays for most covered services, there are limits on the amount that can be charged. The most the doctor or supplier can charge you is 15 percent more than the Medicare-approved amount.
Transplant Services - Under certain conditions Medicare benefits helps pay for immunosuppressive drugs prescribed following organ transplants and certain oral cancer drugs. Chemotherapy for the treatment of disease by means of chemical substances or drugs is also covered. You will need both Part A and Part B in order for Medicare to cover certain dialysis and kidney transplant services.
Medicare Prescription Drug Coverage (Part D) - A new federal program offering prescription drug coverage for Medicare beneficiaries began on January 1, 2006. The Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. This coverage is provided by private companies whose plans are approved by Medicare. Brand-name and generic prescription drugs are covered through participating pharmacies.
Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now.
* You must be enrolled in Medicare Part B.
* You must sign up when you are first eligible or you may pay a penalty.
* To get Medicare prescription drug coverage you can join a Medicare prescription drug plan, you can join a Medicare Advantage Plan or other Medicare Health Plans that offer drug coverage.
* There are no restrictions due to income and resources, health status, or current prescription expenses.
* If you join, you will pay a monthly premium.
* You may be required to pay a yearly deductible, a part of the cost of your prescriptions, a co-payment or coinsurance.
* If you have limited income and resources you may qualify for support services from the New Jersey Department of Health & Senior Services.
Even if you don't use a lot of prescription drugs now, you should still consider enrolling in a Medicare prescription drug plan. For most people, joining now means protecting yourself from unexpected prescription drug bills in the future.
Medicare Extended Coverage
Airway Pressure Device - Medicare Medical Insurance will routinely cover continuous positive airway pressure devices (nose masks) used to help control sleep apena, a condition that causes some people to stop breathing for brief periods during sleep.
Ambulatory Blood Pressure Monitoring - Medicare will cover this system of blood pressure monitoring which involves wearing a cuff that automatically records blood pressure over a 24-hour period. Targeted specifically are those patients with "white coat hypertension", a term meaning that just going into a doctor's office is enough to raise their blood pressure. Medicare does not cover the purchase of this item for private uses.
Chiropractic Coverage - Medicare Medical Insurance will cover manual chiropractic manipulation of the spine and/or physiological function of the spine.
Eyeglasses - Medicare Medical Insurance can help pay for your first pair of glasses after cataract surgery. Medicare may also cover some types of tints and coatings if your doctor prescribes them. The supplier will submit the claim to Medicare.
Foot Care - Medicare Part B Medical Insurance will cover regular foot care once every six months for diabetic patients with peripheral neuropathy, a nerve condition that lessens their ability to feel pain.
Therapeutic Footwear - Medicare Medical Insurance helps pay for fitting and for the cost of one therapeutic pair of shoes and shoe inserts in a calendar year for beneficiaries who have severe diabetic disease. The doctor treating the beneficiary under a comprehensive diabetic care plan must certify the need for the shoes or inserts.
Medicare Preventive Services
Cardiovascular Disease Screening Blood Tests - Medicare will cover blood tests every five years to screen for cholesterol, lipid and triglyceride levels. Medicare will pay 100 percent of its approved amount for these tests, even if you have not yet met the Part B deductible.
Colorectal Cancer Screening - Medicare Part B covers an annual screening fecal occult blood test; a flexible sigmoidoscopy once every 4 years, and a colonoscopy every 10 years for people not at high risk for colorectal cancer and every 2 years if you are at high risk for colorectal cancer or a barium enema as an alternative. You pay nothing for the fecal occult blood test. For all other screening tests (i.e. sigmoidoscopy and colonoscopy), the coinsurance or copayment applies, but the Medicare Part B deductible is waived.
Diabetes Education - Medicare Part B covers a wider range of education and training to teach diabetics to control their blood glucose levels.
Diabetes Glucose Monitoring - All Medicare beneficiaries with diabetes will have coverage for blood glucose monitors, lancets and testing strips. These benefits are subject to the Medicare Part B deductible and coinsurance. Every 12 months Medicare will cover the laboratory tests to screen high-risk individuals for diabetes.
Glaucoma Screening - Medicare Part B now covers an annual dilated eye examination for all people with Medicare at high risk for glaucoma. This includes people with diabetes or a family history of glaucoma. A licensed eye doctor must provide the screening. Medicare covers 80% of the Medicare-approved amount for glaucoma screening after the individual has paid the deductible for Part B services.
Bone Mass Measurement - Medicare will provide one bone mass measurement every two years (24 months) for beneficiaries at risk for osteoporosis and other bone abnormalities. These tests will help to identify bone mass, detect bone loss, or determine bone quality. The tests are subject to the Part B deductible and coinsurance.
Pneumococcal Vaccine - Medicare Part B pays the full-approved charges for pneumococcal vaccine and its administration. A Medicare certified physician must administer the vaccine. No Medicare deductible or coinsurance is applicable.
Preventive Physical Examination - Medicare will cover a one-time initial wellness ("Welcome to Medicare") physical preventive exam in the first six months after a person enrolls in Part B of Medicare. Medicare will pay 80 percent of the Medicare-approved amount after you pay your Part B deductible. Medicare will not cover routine physicals.
Hepatitis B Vaccine - Medicare Part B helps pay for Hepatitis B vaccine administered to beneficiaries considered to be at high or intermediate risk of contracting the disease. A Medicare certified provider must administer the vaccine. This coverage is subject to regular Medicare Part B deductible and coinsurance provisions.
Influenza Virus Vaccine - Medicare Part B will cover an influenza virus vaccine and its administration. Generally, only one influenza virus vaccination is medically necessary per year. Payment for the "Flu Shot" and its administration is at 100% of the Medicare allowed amount when given by doctors who accept Medicare assignment.
"Pap Smear" Screening - Medicare Part B pays for "pap smear" screenings and related medically necessary physician services (including a physician's interpretation of the results of the tests) for female Medicare beneficiaries. Medicare pays for one screening every two years, or more frequently for women at high risk of uterine or vaginal cancers. The Part B deductible is waived but the service is subject to the 20% co-pay.
Prostate Cancer Screening - Medicare Part B will cover annual preventive screenings for prostate cancer for Medicare eligible men age 50 and older. This will include the prostate specific antigen (PSA) test as well as the digital rectal exam. Medicare will pay 100% of the Medicare-approved amount for the PSA test and 80% of the Medicare-approved amount for the digital rectal examination after the annual Medicare Part B deductible is met.
Mammogram - Medicare Part B Insurance helps pay for annual breast examinations, x-ray screenings, and new digital technologies for mammogram screenings. For Medicare-eligible women aged 35 – 39 Medicare pays for a baseline mammogram. For Medicare-eligible women aged 40 and older Medicare pays for an annual mammogram. The Part B deductible is waived, but the 20% co-pay applies. Medicare also pays for diagnostic mammograms as needed when symptoms are present.
Medical Nutrition Therapy - Medicare Part B will cover medical nutrition therapy for people with diabetes, chronic renal disease (but not on dialysis), and post- transplant patients when referred by a doctor. The services must be provided by registered dieticians or other qualified nutrition professionals. Medical nutrition services include nutritional assessment and counseling; an initial visit for an assessment; and follow-up visit for interventions and reassessments to assure compliance with the dietary plan. Medicare covers 80% of the Medicare-approved amount for Medical Nutrition Therapy after the individual has paid the deductible for Part B services.
Durable Medical Equipment/Supplies - Under very specific guidelines, Medicare Part B helps pay for medically necessary equipment that your doctor prescribes for use in your home, such as oxygen equipment, wheelchairs and hospital beds. Certain medical supplies are also covered. Your supplier must have a Medicare approved number.
If you have any questions about claims or payments relating to durable medical equipment or supplies telephone toll-free 1-800-Medicare (1-800-633-4227).
Medicare Part B Carrier - A private insurance company contracts with Medicare to process beneficiary claims,except for Railroad Retirement retirees. More descriptions of services covered under Part B can be found in the MEDICARE AND YOU publication. For Medicare Part B carrier information the toll-free telephone number is 1-800-Medicare (1-800-633-4227). The toll-free telephone for Railroad Retirement Medicare information is 1-800-833-4455 or 1-800-808-0772.
Non-Covered Services Medicare Part A and Part B Services - Medicare does not cover everything. In addition to your premiums, deductibles, and coinsurance, Medicare does not cover:
* routine dental care and dentures
* cosmetic surgery, wigs, hearing aids and routine eye care
* custodial care (help with bathing, dressing, toileting and eating)
* routine foot care and orthopedic shoes
* routine physical exams and acupuncture
* most health care outside the United States and its territories
Medicare Advantage Program (Part C)
The Medicare Advantage program allows beneficiaries to choose to receive their Medicare benefits through a variety of other health delivery options: health maintenance organizations (HMOs), with or without a point of service option, preferred provider organizations (PPOs), provider sponsored organizations (PSOs), private fee-for-service plans (PFFS), medical savings accounts (MSAs), or special needs plans (SNPs). Medicare Advantage plans must provide the same services and benefits (other than hospice care) as are covered under Original Medicare. For information about availability in your area, you may call toll-free 1-800-Medicare (1-800-633-4227).
To be eligible for Medicare Advantage health plans:
* You must have Part A (Hospital Insurance)
* You must have Part B (Medical Insurance)
* You must not have End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant)
* You must live in the geographic and service area where the plan accepts enrollees
Your out-of-pocket costs may depend on:
* Which Medicare health plan you choose
* How often you need health care
* What type of health care you need
* Which extra benefits are covered by the plan
CAUTION: Changing the way you receive your health care is an important decision and should be reviewed carefully before determining which new choices may be right for you. Remember: you do not have to change from Original Medicare.
Medicare Advantage Program Plans
Medicare Advantage Managed Care Plans - Managed care plans provide all of Medicare's benefits and frequently more. They have agreed to provide care to beneficiaries in exchange for a predetermined amount of money from Medicare every month. The managed care plans provide most of Medicare's benefits through a network of doctors and hospitals on an approved list. You generally must receive all covered care through the plan or from health care professionals to whom the plan refers you. Some plans may offer supplemental benefits for which you pay a separate premium. Services may be obtained outside the network if you are willing to pay extra. If you receive services not authorized by the plan, neither the plan nor Medicare will pay.
Medicare Advantage Health Maintenance Organization (HMO) - An HMO involves a group of doctors, hospitals, and other health care providers who have agreed to treat members of the plan. The plans have lock-in requirements. This means you generally receive all covered care through the plan's network of doctors and hospitals. In most cases, if you receive services not authorized by the plan, neither the plan nor Medicare will pay.
Medicare Advantage Preferred-Provider Organization (PPO) (also referred to as Point of Service Plan - POS) - A PPO is a type of managed care plan that allows the beneficiaries to use any doctors or hospitals and other providers who are reimbursed on a fee-for service basis. The insurance plan decides how much to reimburse for the services you receive. Providers may bill more than the plan pays and you will be responsible for paying the difference. Fees charged will be less if use is limited to approved providers.
Provider-Sponsored Organization (PSO) - PSOs are owned and operated by doctors, hospitals or an affiliated group of health care providers that provide a substantial portion of health services to beneficiaries. You must use the plan's doctors, hospitals and affiliated providers.
Religious Fraternal Benefit Society Plans (RFBS) - RFBS plans are offered by a Religious Fraternal Benefit Society that may restrict enrollment to members of the group with which the society is affiliated.
Private Fee-For-Service Plan (PFFS) - A private fee-for-service plan is a Medicare health plan offered by a private insurance company. In a Private Fee-for-Service plan, Medicare pays a set amount of money every month to the private company to provide health care coverage to people with Medicare on a pay-per-visit arrangement.
Each year, the insurance companies offering Private Fee-for-Service plans can decide to join or leave Medicare.
* In Private Fee-for-Service plans, you may go to any doctor or hospital
* You can get services outside your service area
* You get all services covered under Medicare Part A and Part B
* You may have extra benefits the Medicare Plan does not cover, like outpatient prescription drugs, but you may have to pay more for these extra benefits
* Private Fee-for-Service plans can charge you a premium amount above the Medicare Part B premium
* Private Fee-for-Service plans can charge deductible and coinsurance amounts that are different than those under the Original Medicare Plan
Private Fee-for-Service plans may let providers charge you 15% over the plan's payment amount for services. This 15% balance billing amount applies to providers who have a written contract with the Private Fee-for-Service Plan or who the company has decided to think of as having a contract because they have met certain conditions. If the provider does not have a contract with the Private Fee-for-Service plan, or is not deemed to have a contract with the plan, the provider cannot charge you more than the plan's cost sharing amount. Because this could affect how much you will pay for services, find out if your Private Fee-for-Service plan allows balance billing and what other costs you may have. Even if balance billing is allowed, your provider may be willing to accept the plan's payment in full.
Note: The insurance company, rather than the Medicare Program, decides how much you pay for the services you get.
Medicare Special Needs Plan (SPN) - A special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home or have certain chronic medical conditions.
Medicare Advantage Medical Savings Account (MSA) - MSA Plans combine a high deductible Medicare Advantage Plan (like an HOM or PPO) with a Medical Savings Account for medical expenses. A Medicare MSA Plan has two parts. One part is the Medicare MSA, a special type of savings account. We will call this the "Account." The Account holds money for you to use to pay your medical bills. The money in your Account is not taxed if it is used for qualified medical expenses, and it may earn interest or dividends.
The other part of a Medicare MSA Plan is the Medicare MSA Health Policy. We will call this the "Policy." This is a special health insurance policy that has a high annual deductible. You choose the Policy you want to use as part of your Medicare MSA Plan. The Medicare program must have approved this Policy. An insurance company offers the Policy to you, and it must be designed to work as part of a Medicare MSA Plan. You also choose the bank or other institution where your Account is set up. The bank or institution (called a trustee or custodian of your Account) must be registered with the Medicare program to set up Medicare MSAs. When you have chosen a policy and set up your Account, your Medicare MSA Plan is complete and ready to work.
You enroll in a Medicare MSA Plan for a year, January through December. At the beginning of the year, the Medicare program makes a deposit in your Account for the entire year. You can use that money to pay for your health care. Every month, the Medicare program (not you) pays a premium for your Policy to the insurance company. Your Policy must offer all Medicare covered benefits. Some Policies may cover additional benefits. If you meet your Policy's deductible, your Policy coverage begins and helps you pay your bills after that (for benefits that the Policy covers). You may be able to choose any doctor or provider for your medical care, or your Policy may limit your choice of doctors and other providers depending on the Policy you choose.
Medicare as Secondary Payer
Medicare has special rules that apply to beneficiaries who have employer group health plan coverage through their employment or the employment of a spouse. Group health plans of employers with 20 or more employees are required to offer workers age 65 or over and workers' spouses who are age 65 or over the same health insurance benefits under the same conditions offered to younger workers and spouses. In such situations, you and your spouse have the option to accept or reject your employer's group health plan. If you accept your employer's health plan, it will pay first on your health claims; Medicare will become the secondary payer. If you reject your employer's health plan, Medicare will remain the primary health insurance payer. If you elect Medicare to be the primary payer, your employer plan cannot offer you coverage that supplements Medicare. If your employer plan denies you coverage, offers you different coverage, or pays benefits that are secondary to Medicare, notify Medicare by calling 1-800-Medicare (1-800-633-4227).
Original Medicare Appeals - If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you received, you have the right to appeal the decision. The notice you receive from Medicare tells you the decision made on the disputed claims and also tells you exactly what appeal steps you can take. If you ever need more information about your right to appeal and how to request it, call Social Security or Medicare at 1-800-Medicare (1-800-633-4227). Your Area Agency on Aging or State Health Insurance Assistance Program (SHIP) can also offer direction.
Medicare Fraud and Abuse - The majority of physicians, providers, and suppliers who serve people with Medicare provide high quality care to their patients and bill the program only for the payments they have earned. There are a few individuals who may attempt to defraud (cheat) Medicare. If you suspect other than proper billing has been provided to Medicare for the services rendered to you, please call 732-777-1940 or 1-877-678-4697.
Medicare Savings Programs
The Medicare Savings Program may help pay part of your medical expenses. If you qualify, you may not have to pay your Medicare Part A and B premiums, deductibles, and coinsurance premiums or out of pocket expenses. The savings plans are:
Specified Low-Income Medicare Beneficiary (SLMB) - Certain individuals who have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) and who are slightly above the national poverty level may qualify for State help in paying their Medicare Part B premium. To qualify, a person's annual gross income must not exceed 135% of the Federal Poverty Level and their financial resources such as bank accounts, stocks, and bonds must be within established limits. The Medicare Part B premium must be included in determining annual gross income.
Qualified Medicare Beneficiary (QMB) - The Qualified Medicare Beneficiary (QMB) in NJ is a component of the NEW JERSEY CARE program. QMB also helps pay for the Medicare Part B premium, deductibles and coinsurance. The QMB program has slightly lower income guidelines but the same asset guidelines as the SLMB program.
Qualifying Individual (QI-1) - Persons with income between 120% and 135% of the Federal Poverty Level may be eligible for assistance as a Qualifying Individual (QI) to have monthly Medicare Part B premiums paid.
Medicaid
Medicaid is a joint federal-state medical assistance program that pays medical bills for certain individuals of any age with low income and limited resources. In NJ, persons eligible for Supplemental Security Income (SSI) are also eligible for Medicaid, and automatically receive it.
Persons 65+, or blind or disabled planning to live in a non-institutional type setting should contact Social Security (1-800-772-1213) to determine if they are eligible for Supplemental Security Income (SSI), since those eligible for SSI also receive Medicaid. Persons seeking Medicaid assistance for institutional care should contact the Board of Social Services/Welfare Office in their county to determine if they are eligible for Institutional Medicaid.
NOTE: In NJ, persons may also qualify for Medicaid under the NEW JERSEY CARE program. Income and resource guidelines are slightly higher than those under Medicaid through SSI. Please call your County Board of Social Services for information on NEW JERSEY CARE.
Group Health Insurance
Continuing Coverage After Leaving Employment (COBRA) - Employees covered by an employer-provided group health insurance policy covering more than 20 persons, leaving the employ of their employer for any reason except gross misconduct, are entitled to a minimum of 18 months continuation of their group health insurance policy at group rates for themselves and their families provided that they are not covered by another group health insurance policy, and provided that the employer's policy remains in effect.
For information governing such continuance, contact the Employee Benefits Security Administration, Division of Technical Assistance and Inquiries, US Department of Labor, 200 Constitution Avenue, N.W., Room N-5658, Washington, DC 20210, telephone toll-free 1-866-487-2365 or 202-219-8776, or www.dol.gov.
Federally Qualified Health Centers - Medicare (FQHCs)
Medicare benefits have been expanded to include payment for certain preventive health-care services provided in federally qualified health centers (FQHCs). In addition, FQHCs may waive the deductible normally required under Medicare Part B and may limit the out-of-pocket costs by applying the co-pay responsibility of the Medicare beneficiary to a sliding scale based upon the beneficiary's ability to pay.
The FQHCs do not charge for any service for which Medicare beneficiaries are entitled to have payment made by the Medicare program. In order to be covered under Medicare Part B (Medical Insurance) the FQHCs must meet the U. S. Public Health Service criteria and agree to meet Medicare requirements.
In New Jersey, FQHCs are located in Atlantic, Camden, Cumberland, Essex, Hudson, Mercer, Middlesex, Passaic, Salem and Union counties. Anyone living in these counties should contact the Area Agency on Aging for the location of the FQHC. The FQHC can provide eligibility guidelines and information on services provided.
Seniors Center
Seniors Center
