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| Medicare FAQs |
| the Health Care Financing Administration |
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the Social Security Administration and Medicare.
What is the difference
between Medicare and Medicaid?
What are the
requirements to receive Medicare benefits?
What are the
requirements to receive Medicare Medical Insurance
?
I'll be 65 years old soon.
When should I sign up for Medicare
?
What is the difference between
Medicare Part A and Medicare Part B
?
Do you
automatically get
Medicare if you are getting Social Security disability benefits?
When will I get my Medicaid card
?
I have
unpaid bills
already. Will Medicaid help pay for these?
Does Medicare pay for
prescription drugs
?
Why is Social Security
still taking money out each month towards Medicare Part B
when I have joined a Medicare managed care plan?
What is "
assignment
" in the Original Medicare Plan, and why is it important?
How is the
privacy of my medical records
protected?
Am I still responsible for the 20% coinsurance amount
if my doctor submits the claim too late
and it's denied for late filing?
Does the Medicare
cover me when I travel
outside of the United States?
What is the difference between Medicare
fraud and abuse
?
Why does it take so long to
resolve my complaint
about Medicare fraud and abuse?
What are the consequences if a Medicare
provider commits fraud
?
Why does Medicare pay so much for
items that I can get more cheaply
?
Why was my Medicare
claim denied
?
What is the cut-off date for
sending in monthly premium
payments?
What agency should I contact if I'm
due a refund
?
Q:
What is the difference between Medicare and Medicaid?
A:
Medicare is an insurance program. Medical bills are paid from trust funds that those who are covered have paid into. It primarily serves people over 65 and younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.
Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments according to federal guidelines
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Q:
What are the requirements to receive Medicare hospital insurance?
A:
Most people 65 or older are eligible for Medicare hospital insurance (Part A) based on their own- or their spouse's? employment. You are eligible at 65 if you:
- Receive Social Security or railroad retirement benefits
- Aren't getting Social Security or railroad retirement benefits, but you have worked long enough to be eligible for them
- Would be entitled to Social Security benefits based on your spouse's (or divorced spouse's) work record, and that spouse is at least 62 (your spouse doesn't have to apply for benefits in order for you to be eligible based on your spouse's work) ;or
- Worked long enough in a federal, state, or local government job to be insured for Medicare
If You Are Under 65
Before age 65, you are eligible for Medicare hospital insurance if you:
- Have been a Social Security disability beneficiary for 24 months; or
- Have worked long enough in a federal, state, or local government job and you meet the requirements of the Social Security disability program
If you receive a disability annuity from the Railroad Retirement Board, you will be eligible for hospital insurance after a waiting period. (Contact your railroad retirement office for details.)
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Q:
What are the requirements to receive Medicare Medical Insurance?
A:
Almost anyone who is 65 or older or who is under 65 but eligible for hospital insurance can enroll for Medicare medical insurance by paying a monthly premium. You don't need any Social Security or government work credits for this part of Medicare.
Aliens who are 65 or older and aren't eligible for hospital insurance must be lawfully admitted permanent residents and must live in the United States for five years before they can enroll for medical insurance.
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Q:
I'll be 65 years old soon. When should I sign up for Medicare?
A:
Generally, you should file for Medicare benefits three months before turning age 65. Remember, Medicare benefits can begin no earlier than age 65. If you are already receiving cash benefits, you will automatically be entitled to Medicare without an additional application. You will receive a Medicare card about two months before turning age 65.
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Q:
What is the difference between Medicare Part A and Medicare Part B?
A:
There are two parts to Medicare: Hospital Insurance (sometimes called Part A) and Medical Insurance (sometimes called Part B). Generally, people who are over age 65 and getting Social Security automatically qualify for Medicare. So do people who have been getting disability benefits for two years. Part A is paid for by a portion of the Social Security tax of people still working. It helps pay for inpatient hospital care, skilled nursing care and other services. Part B is paid for by monthly premiums of those who are enrolled. It helps pay for such items as doctor's fees, outpatient hospital visits and other medical services and supplies.
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Q:
Do you automatically get Medicare if you are getting Social Security disability benefits?
A:
You will automatically be enrolled in Medicare after you get social security disability benefits for two years. This starts 24 months from the month you were entitled to receive social security disability benefits. In some cases, this could be earlier than the month when you received your first check. You can get more information from the Social Security Administration at 1-800-772-1213 or on their http://www.ssa.gov .
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Q:
When will I get my Medicaid card?
A:
It takes about four weeks for Medicaid to get information from Social Security. Once that information comes to Medicaid, a plastic Medicaid card will be issued. You will get your card about two to three weeks after Medicaid receives your information. It takes time for the information to go first to the Social Security office in Baltimore, Maryland, then on to Medicaid. This step is necessary in order for your checks to be processed.
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Q:
I have unpaid bills already. Will Medicaid help pay for these?
A:
If you had medical bills in the three months before you applied for SSI, Medicaid may be able to pay some of these bills. In order for Medicaid to do this, you must contact the Medicaid District Office that serves the county where you live. Ask to apply for "retroactive eligibility." You have six months from the day you were approved for SSI to do this.
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Q:
Does Medicare pay for prescription drugs?
A:
The Original Medicare Plan doesn't cover prescription drugs except in a few cases, such as certain cancer drugs. Many Medicare + Choice plans cover prescription drugs, up to certain dollar limits (sometimes for an extra cost). Some Medigap policies and states also cover prescription drugs.
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Q:
Why is Social Security still taking money out each month towards Medicare Part B when I have joined a Medicare-managed care plan?
A:
You must continue to pay the monthly Medicare Part B premium of $54.00 in 2002 when you join a Medicare managed care plan. You may also have to pay an additional monthly premium to the plan. If you join a Medicare-managed care plan, you are still in the Medicare program and are still entitled to get all your regular Medicare-covered services and have Medicare rights and protections.
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Q:
What is "assignment" in the Original Medicare Plan and why is it important?
A:
Assignment is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies (like wheelchairs, oxygen, braces, and ostomy supplies). Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Part B services and supplies. You pay the coinsurance and deductible amounts. In some cases (such as if you have both Medicare and Medicaid), your health care providers and suppliers must accept assignment.
If assignment isn't accepted, charges are often higher. This means you may pay more. In addition, you may have to pay the entire charge at the time of service. Medicare will then send you its share of the charge.
There is a limit on the amount your doctors and providers can bill you. The highest amount of money you can be charged for a covered service by doctors and other health care providers who don't accept assignment is called the "limiting charge." The limit is 15% over Medicare's approved amount. The limiting charge only applies to certain services and doesn't apply to supplies or equipment.
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Q:
How is the privacy of my medical records protected?
A:
You have the right to talk with health care providers in private and to have your personal health care information kept private as protected under federal and state laws.
There is a new patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used by your health care provider or your health plan. This rule will be fully effective on April 14, 2003.
If you have any questions about this privacy rule, look at the National Standards to Protect the Privacy of Personal Health Information, http://www.hhs.gov/ocr/hipaa, on the web.
If you are in a Medicare-managed care plan or a Medicare Private Fee-for-Service plan, you also have the right to timely access to your medical records.
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Q:
Am I still responsible for the 20% coinsurance amount if my doctor submits the claim too late and it's denied for late filing?
A:
Providers must submit claims to Medicare on their patient's behalf. Although providers have between 15-27 months to submit a claim for reimbursement based on the date of service, sometimes a claim is not submitted timely and not considered for payment by Medicare. However, you are still responsible for the 20% coinsurance amount based on what Medicare would have allowed for the service had it not been submitted late. Your Medicare Summary Notice will inform you of the amount you are responsible to pay your provider.
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Q:
Does Medicare cover me when I travel outside of the United States?
A:
The Original Medicare Plan doesn't cover health care when you travel outside the United States, except for some emergency situations in Mexico and Canada. Some Medicare + Choice plans and Medigap policies cover you when you travel outside the United States. Check with your plan or insurance coverage before you travel outside the country.
In rare cases, Medicare can pay for inpatient hospital services that you get in Canada or Mexico. Medicare can pay only if:
* You are in the United States when a medical emergency occurs and the Canadian or Mexican hospital is closer than the nearest U.S. hospital that can treat the emergency
- You are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency
- You live in the United States and the Canadian or Mexican hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.
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Q:
What is the difference between Medicare fraud and abuse?
A:
Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment. Keep in mind that the attempt itself is fraud, regardless of whether it's successful.
Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person's intent. Both have the same impact: they steal valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.
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Q:
Why does it take so long to resolve my complaint about Medicare Fraud and Abuse?
A:
All Medicare contractors (the intermediaries and carriers that contract with HCFA to process Medicare claims) have Medicare Fraud Units in place to detect, deter and prevent fraud and abuse. In addition to the other workload that these units have, they receive and respond to a large number of complaints. Some of these complaints involve fraud and abuse, while others are simple misunderstandings. The Fraud Unit staff must treat each complaint seriously. This means that they meticulously investigate each case. Investigations may involve a number of steps, including:
- Sending surveys to a random sample of beneficiaries
- Speaking to beneficiaries on the phone
- Obtaining medical records from providers
- Conducting on-site audits
- Writing a report on the investigation
After the Fraud Unit has completed its investigation, the case is often referred to federal law enforcement and then on to the U.S. Attorney for criminal or civil prosecution. Obviously, this process takes a considerable amount of time.
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Q:
What are the consequences if a Medicare provider commits fraud?
A:
Fraud Units refer the results of their investigations to the U.S. Dept. Of Health and Human Services Office of the Inspector General ("OIG"). The OIG's Office of Investigations then prepares the case for referral to the Department of Justice for criminal and/or civil prosecution.
A person who is found guilty of committing Medicare fraud faces a host of different criminal, civil, and administrative sanction penalties including:
- Civil penalties of $5,000 to $10,000 per false claim and treble damages under the False Claims Act
- Criminal fines and/or imprisonment of up to 10 years if convicted of the crime of Health Care Fraud as provided in the Health Insurance Portability and Accountability Act of 1996 or, for violations of the Medicare/Medicaid Anti-Kickback Statute, imprisonment of up to five years, and/or a criminal fine of up to $25,000
- Administrative sanctions including up to a $10,000 civil monetary penalty per line item on a false claim, assessments of up to treble the amount falsely claimed, and/or exclusion from participation in Medicare and State health care programs
In addition to the penalties outlined above, those who commit health care fraud can also be tried for Mail and Wire Fraud. It has never been more dangerous to commit Medicare Fraud.
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Q:
Why does Medicare pay so much for items that I can get more cheaply?
A:
Congress sets the prices Medicare pays for many items. These prices often do not take into account rebates that may be available from retail establishments. For example, Medicare pays a fixed amount for the glucometer that a diabetic uses to test his blood sugar. Many of these items currently have rebates that make them less inexpensive. Medicare cannot take into account such discounts.
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Q:
Why was my Medicare claim denied?
A:
To find out why your Medicare claim was denied, contact the Medicare contractor in your state. This number can be found under your state's name in the Local Information section of HCFA's web site.
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Q:
What is the cut-off date for sending in monthly premium payments?
A:
Payments must be received in the premium collection center by the 25th of the month to ensure they are credited timely for that month. If you submit a payment that is greater than your bill amount, you will not receive bills until your account reflects a balance due. If your payment arrives after the due date, your next monthly or quarterly bill will include the amount for the previous period.
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Q:
What agency should I contact if I'm due a refund?
A:
Contact the Social Security Administration at 1-800-772-1213 to find out the Payment Service Center responsible for servicing you social security number.
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Information courtesy of the Health Care Financing Administration, the Social Security Administration and Medicare.
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