July 26, 2010
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Index to Manual Cover Page
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Index To Manual
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Medicaid Overview
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NC Medicaid Eligibility & (Chart) NC Medicaid Application
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How To Apply for NC Medicaid Who is Eligible
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BE Smart Family Planning Program
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Medicaid For Infants & Children …………………
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Medicaid For Pregnant Woman ……………………
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Community Alternative Program (CAP/C) …
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Baby Love Program
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HealthCheck and EPSDT Forms
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Following Sections: MEDICARE | MEDIGAP | MISC
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MEDICAID Overview What is Medicaid? •
Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. Medicaid is a little different, depending on who you are and your situation. See who is eligible.
•
Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.
•
Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services.
•
Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for disabled children living at home.
•
Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents). Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.
•
In general, you should apply for Medicaid if your income is low and you match one of the descriptions of the Eligibility Groups. (Even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation.)
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When Eligibility Starts Coverage may start retroactive to any or all of the 3 months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most States have additional "State-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for State-only programs.
What is Not Covered Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.
What Does Medicaid Cover? Medicaid may help pay for certain medical expenses such as: • • • • • • • • • • •
Doctor Bills Hospital Bills Prescriptions (Excluding prescriptions for Medicare beneficiaries) Vision Care Dental Care Medicare Premiums Nursing Home Care Personal Care Services (PCS), Medical Equipment, and Other Home Health Services In-home care under the Community Alternatives Program (CAP) Mental Health Care Most medically necessary services for children under age 21
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NC Medicaid Eligibility Who is Eligible for Medicaid? (General) Medicaid serves low-income parents, children, seniors, and people with disabilities. There are different types of coverage for people with different needs. Income and resource limits for each of these groups vary: • • • •
Aged, Blind and Disabled Infants, Children and Families Long-Term Care Medicare Recipients
To be eligible for Medicaid, you must also: •
• •
Be a U.S. citizen or provide proof of eligible immigration status. Individuals only applying for emergency services are not required to provide documentation of immigration status. Live in North Carolina, and provide proof of residency. Have a Social Security number or have applied for one.
You are automatically eligible for Medicaid if you receive any of the following benefits: • • • •
Supplemental Security Income (SSI) Work First Family Assistance State/County Special Assistance for the Aged or Disabled (Adult Care Home Assistance ) Special Assistance to the Blind
To receive Medicaid, you do not have to go through a physical or other type of exam. However, if you are applying because you are disabled, a medical exam may be required. If you are applying for Medicaid because you are pregnant, proof of pregnancy is required.
See Chart for NC Medicaid Eligibility on the following pages:
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MEDICAID ELIGIBILITY BASIC REQUIREMENTS 1 GROUP
BENEFITS
Basic Eligibility Requirement
Whose Income and Resources Count
Income Limit (updated 04/09)
Resource Limit
Deductible/ Spenddown
Recipients of Full Medicaid Cash coverage Assistance Programs
Aged
Blind
Disabled
Health Care for Working Disabled (HCWD) Qualified Medicare Beneficiaries
Specified Low Income Medicare Beneficiaries Qualifying Individuals
Working Disabled
1
Recipients of the following cash assistance programs are automatically entitled to Medicaid. No separate Medicaid application or Medicaid eligibility determination are required. The cash assistance programs are: • Work First Family Assistance – NC program under the federal Temporary Assistance to Needy Families law that provides cash assistance to families with children. • Supplemental Security Income (SSI) – Federal cash assistance program for the aged, blind, and disabled. • State/County Special Assistance – State cash assistance program for aged and disabled individuals, primarily who are in adult care homes. • Special Assistance to the Blind – State cash assistance program for blind individuals. Full Medicaid Age 65 or older Spouse’s income and resources 100% of Poverty SSI Limits Yes If income exceeds income limit and the indicator is Coverage if live together 1 – $ 903/mo 1 - $2,000 “yes,” the individual or 2 – $1,215 /mo 2 - $3,000 family may be able to be Full Medicaid Blind by Social Spouse’s income and resources Yes 100% of Poverty SSI Limits eligible for Medicaid if they Coverage Security if live together. Parents’ income 1 – $ 903/mo 1 - $2,000 can meet a deductible. Standards and resources if under age 18 2 – $1,215 /mo 2 - $3,000 See discussion of Medical and live with parents. Deductible on page 2 of Full Medicaid Disabled by Spouse’s income and resources 100% of Poverty SSI Limits Yes this same column. Coverage Social Security if live together. Parents’ income 1 – $ 903/mo 1 - $2,000 Standards and resources if under age 18 2 – $1,215 /mo 2 - $3,000 and live with parents. Individuals in nursing Full Medicaid Blind or Disabled Spouse’s income and resources Min. CSRP No 150% of Poverty facilities generally do not Coverage by Social limit if live together. Parents’ income 1- $1,354 have to meet a deductible Security and resources if under age 18 $21,912 to be eligible for Medicaid. 2- $1,822 Standards and live with parents. However, they must pay all Age 16-64 of their monthly income, Payment of Medicare No Entitled to Spouse’s income and resources less a $30 personal needs 100% of Poverty 2 x SSI premiums and Medicare Parts A if live together. Parents’ income allowance and the cost of Limits 1 – $ 903/mo deductibles and co&B and resources if under age 18 medical expenses not 2 – $1,215 /mo 1 - $4,000 insurance charges for and live with parents. covered by Medicaid or 2 - $6,000 Medicare covered other insurance to the services nursing facility. Medicaid pays the remainder of their Payment of Medicare Entitled to free Spouse’s income and resources No 120% of Poverty 2 x SSI cost of care. Part B premium Medicare Part A if live together. Parents’ income 1 - $1,083/mo Limits and resources if under age 18 2 - $1,457 /mo 1 - $4,000 and live with parents. 2 - $6,000 Payment of Medicare Entitled to free Spouse’s income and resources No 135% of Poverty 2 x SSI Part B Premiums Medicare Part A if live together. Parents’ income 1 - $1,219 mo Limits and resources if under age 18 2 - $1,640/mo 1 - $4,000 and live with parents. 2 - $6,000 NOTE: Total number of eligible individuals is limited to available funds. Payment of Medicare Lost entitlement Spouse’s income and resources No 200% of Poverty 2 x SSI Part A premiums to free Medicare if live together. Parents’ income 1 - $1,805/mo Limits A due to and resources if under age 18 2 - $2,429/mo 1 - $4,000 earnings but still and live with parents. 2 - $6,000 has disabling impairment.
SPECIAL PROVISIONS (updated 07/09)
Protection of income for spouse at home: When an individual is in a nursing facility and has a spouse living at home, a portion of the income of the spouse in the facility may be protected to bring the income of the spouse at home up to a level specified by federal law. Currently, that amount is $1,822 /mo and can be as much as $2,739 depending upon at-home spouse’s cost for housing. The amount protected for the at-home spouse is not counted in determining the eligibility of the spouse in the nursing facility. Protection of resources for spouse at home: Additionally, the countable resources of the couple are combined and a portion is protected for the spouse at home. That portion is ½ the total value of the countable resources, but currently not less than $21,912 or more than $109,560. The amount protected for the at-home spouse is not countable in determining the eligibility of the spouse in the facility. Transfer of resources: When a person gives away resources and does not receive compensation with a value at least equal to that of the resources given away, he may be penalized. Medicaid will not pay for care in a nursing facility or care provided under the Community Alternative Placement program or other in-home health services & supplies for a period of time that depends on the value of the transferred resource.
This chart addresses benefits and basic eligibility requirements. Other requirements (such as citizenship/alien status, incarceration, & state residence) which can also affect eligibility or the level of benefits are not reflected on this chart. Rev. 07/09
GROUP
BENEFITS
Basic Eligibility Requirement
Whose Income and Resources Count
BASIC REQUIREMENTS Income Limit Resource (update 4/09) Limit
Families & Children
Full Medicaid coverage
Parents/Caretaker relatives must be living with and caring for a child to whom they are related who is under age 19. Children must be under age 21.
Spouse’s income and resources if live together. Parents’ income and resources if under age 21 and live with parents.
1 - $362/mo 2 - $472/mo 3 - $544/mo 4 - $594/mo 5 - $648/mo
Pregnant Women
Coverage is limited to treatment for conditions that affect the pregnancy.
Medical verification of pregnancy
Count only the income of the pregnant woman and her spouse if married.
185% of Poverty
Children under age 6
Full Medicaid Coverage
Be under age 6.
Parents’ income if living in the home.
200% of Poverty
Children age 6 thru 18
Full Medicaid Coverage
Be age 6 thru age 18
Parents’ income if living in the home.
100% of Poverty
Title IV-E Children
Full Medicaid Coverage
Be an Title IV-E adoptive or foster child
State Foster Care Children (HSF)
Full Medicaid Coverage
Expanded Foster Care
Full Medicaid Coverage
Be 18-20 and had been a Title IV-E or State th foster child on 18 birthday
None
Breast & Cervical Cancer Medicaid
Full Medicaid Coverage
A woman who has been screened and enrolled in the NC Breast &Cervical Cancer Control Program and is otherwise ineligible for Medicaid
Medicaid eligibility is automatic. There is no income or resource determination.
1
1 - $1,670/mo 2 - $2,247 /mo 3 - $2,823/mo 4 - $3,400 /mo 5 - $3,976/mo
1 - $1,805/mo 2 - $2,429/mo 3 - $3,052/mo 4 - $3,675/mo 5 - $4,299/mo 1 - $ 903/mo 2 - $1,215 /mo 3 - $1,526/mo 4 - $1,838/mo 5 - $2,150/mo
$3,000
No resource limit if eligible with income no more than 185% of poverty
No resource limit if eligible with income no more than 200% of poverty No resource limit if eligible with income no more than 100% of poverty.
Medicaid eligibility is automatic. There is no income or resource determination.
State Foster Care Children are evaluated as Families and Children’s Group above. (If not eligible for HSF, then evaluate for other children’s programs.)
None
None
Deductible/Spenddown Yes
If income exceeds income limit and the indicator is “yes” the individual or family may be able to be eligible for Medicaid if they he can meet a deductible
Medicaid Deductible: When an individual/family is ineligible for Medicaid due to income over the income limit, they may become eligible by meeting a Medicaid deductible. The deductible is determined by subtracting the Medically Needy Income Limit (MNIL) (see limits below) from the Yes countable monthly income to determine the monthly excess income. Medicaid deductibles are generally determined for 6 months, so the monthly excess income is multiplied by 6 to determine the 6-mo. Yes deductible. Once medical bills for which they are responsible totaling the amount of the deductible are incurred, they are authorized for the restr of the 6-mo. period. Medicaid cannot pay for any of the bills applied to the deductible. Resource limit: MNIL: No 1 - $242/mo All deductible cases have a Yes 2 - $317/mo 3 - $367/mo resource limit: $3000 for 4 - $400/mo families and 5 - $433/mo children and No $2,000 (1) and $3000 (2) for aged, blind and disabled. No Yes
SPECIAL PROVISIONS (updated 04/09) Children with special needs who are adopted under state adoption agreements have their eligibility for Medicaid determined without counting the income of the adoptive parents. When determining the family size for the pregnant woman the unborn child is included. For example the family size for a single pregnant woman would be 2.
To be eligible under the Breast and Cervical Cancer Medicaid program, the woman can have no medical insurance coverage including Medicare.
GROUP Family Planning
NC Health Choice (NCHC)
BENEFITS Family Planning exams & services. Screening & treatment for STI. Screenings for HIV. Sterilizations.
Coverage of the NC State Employees Health Plan, plus vision, hearing, & dental
BASIC REQUIREMENTS Income Limit Resource (update 4/09) Limit
Deductible/Spenddown
Basic Eligibility Requirement
Whose Income and Resources Count
Women age 19 thru 55 Men age 19 thru 60 Not otherwise eligible for Medicaid
Count spouse’s income. Do not count parent’s income for children.
185% of Poverty 1 - $1,670/mo 2 - $2,247/mo 3 - $2,823/mo 4 - $3,400 /mo 5 - $3,976 /mo
No resource limit
No
There is no deductible or spenddown provision for Family Planning coverage. If a recipient’s income increases to more than 185%, he will be ineligible for family planning coverage
Be an uninsured child over age 5 & under age 19.
Parents’ income if living in the home.
200% of Poverty 1 - $1,805/mo 2 - $2,429/mo 3 - $3,052/mo 4 - $3,675/mo 5 - $4,299/mo
No resource limit
Np
There is no deductible or spenddown provision for NCHC. If a child is ineligible due to too much income, they will be evaluated for Medicaid with a deductible.
SPECIAL PROVISIONS (updated 04/09)
Income over 150% of poverty, must pay enrollment fee. 1 - $1,354 2.-.$1,822 3 - $2,289 4 - $2,757 5 - $3,224
MEDICAID Application Who is Eligible - Aged, Blind & Disabled You may be eligible for Medicaid if you are age 65 or older, blind, or disabled. Eligibility for Medicaid is based on your family’s monthly income and the amount of resources you own. To receive Medicaid for the blind or disabled, you must be evaluated by a doctor. Effective November 1, 2008, a disabled and/or blind individual may be able to go to work or increase their hours of work and still receive Medicaid through the Health Coverage for Workers with Disabilities Act. If you receive Supplemental Security Income, you are eligible for North Carolina Medicaid. You do not need to apply. When you apply for Medicaid, your family’s monthly income is calculated by subtracting certain deductions from your gross income. Social Security, veteran’s benefits, wages, pensions and other retirement income are counted. The deductions vary with each Medicaid program. Your county worker will calculate your monthly family income. Your monthly countable income cannot be more than the amounts listed below. Monthly Income Limits for Medicaid for Adults (Effective 04/2009) Family size 1 2 Monthly Income Limit $903 $1,215 Your resources may not be more than $2,000 for an individual or $3,000 for a couple. Resources include the following: • • • • • •
cash bank accounts retirement accounts stocks and bonds cash value of life insurance policies other investments.
The value of your home, a car, home furnishing, clothing and jewelry are not counted. If your family income and/or resources are over the limit and you have high medical bills, you may still qualify for Medicaid and have a Medicaid deductible.
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How to Apply for NC Medicaid * If you receive Supplemental Security Income (SSI), you are automatically covered for North Carolina Medicaid. You do not need to apply for Medicaid.
Applying in Person You may apply at the County Department of Social Services (DSS) in the county where you live. If possible, take the items listed below with you when you go to the DSS office to apply. If you do not have some or all of these items, please apply anyway because it is very important to protect your application date. The DSS can assist you in obtaining these items and information. • • •
• • •
• • •
Certified birth certificates or other proof of citizenship/alien status for each individual applying for Medicaid/NCHC Identity documents for each individual applying for Medicaid/NCHC Social security cards, social security numbers, or proof that you have made an application for a number from the Social Security Office, for each individual applying for Medicaid or NCHC A copy of all pay stubs for last month Copies of all medical or life insurance policies A list of all cars, trucks, motorcycles, boats, etc. you or anyone in your household own, including the year, make, model, and vehicle identification number (VIN) for each item Most recent bank statements A list of all real property you own Current financial statements/award letters from other sources of income, such as social security, retirement benefits, pensions, veteran benefits, and child support.
You are not required to bring an application with you, but it may speed the process to print and fill out as much of the application as you can ahead of time.
If You are Unable to Apply in Person If you are unable to go to a DSS office, you may also print and mail completed Medicaid and Health Choice Applications to your local DSS office. Or you may call and ask that an application form be mailed to you. If you are disabled, a county representative may be able to make a home visit to assist you with the application process. Faxed applications and applications received over the internet are not acceptable. Some health centers and hospitals have application forms available and may be able to assist you in completing them. Page | 10
Who is Eligible - Infants, Children, & Families Medicaid serves infants, children, and families in several ways: • • • • • • •
Family Planning: Be Smart Medicaid for Infants and Children Medicaid for Families with Dependent Children (for parents or other caretakers) Medicaid for Pregnant Women Community Alternatives Programs: For children who need long-term care Baby Love: A combination of services designed to help you have a healthy baby. Health Check and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) covers medically necessary health care services to Medicaid-eligible children.
Your family’s income, the number of people in your family, and the age of your children determine if you or your children qualify. When you apply for Medicaid, your family’s monthly income is calculated by subtracting certain deductions from your gross income. Certain deductions are given for work-related expenses, child care costs, and court-ordered child support or alimony. The deductions vary with each Medicaid program. Your county worker will calculate your monthly family income.
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Be Smart Family Planning Program Be Smart Information for Providers
Are you ready to be a mom or dad? Are you ready for another child? Do you think you might want more children? If you answered no to any of these questions, you may qualify to receive birth control methods and health care services for free. The Be Smart Family Planning Waiver (FPW) Program is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina. The Be-Smart Program: • • • •
Provides family planning and birth control; Is free - there is no cost for the services; Is voluntary; and Is confidential.
Who Can Apply for Be Smart? • • • •
• •
Women ages 19 through 55 Men ages 19 through 60 U.S. citizens or documented immigrants North Carolina residents who: o Are not pregnant; o Are not sterilized; o Are not incarcerated; and o Have income at or below 185% of the federal poverty level. Not currently on Medicaid Other requirements may apply.
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What Does Be Smart Provide? • • • • • • • • • • •
Family planning initial and yearly exams; Follow-up family planning visits; Birth control and family planning counseling; Pregnancy tests; Some types of birth control methods like the pill, the shot, and IUDS, as well as vasectomies and tubal ligations; Family Planning Lab tests; HIV testing Limited screening and treatment for some STDs (limited to the inital family planning visit) Pap smears; Help on when to have a baby; and Referrals
Where Can I Go for Family Planning Services? Any participating family planning provider enrolled with Medicaid can provide Be Smart services. • Private Medical Providers • Local Health Departments • Federally Qualified Health Centers • Rural Health Clinics • Planned Parenthoods
What is Not Covered? • • • • • • • • • • • • • • • • •
Dental Fertility testing and treatment Hysterectomies Abortions Pregnancy health care Ambulance Condoms Contraceptive Foam, Jellies, or Suppositories Durable Medical Equipment Home Health Inpatient Hospital Mental Health Optical Treatment for AIDS Treatment for Cancer Sick Visits Any service not related to Family Planning Page | 13
For More Information about the Be Smart Family Planning Waiver (FPW) Program You can call your County DSS office or your Local Health Department. You may also call the North Carolina Family Health Resource Line at 1-800-367-2229. Family Planning Medicaid is a program that will end October 1, 2010, unless it is extended.
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Medicaid for Infants and Children Medicaid for Infants and Children (MIC) provides medical coverage for children under age 19. The income limits are determined by the family size and the age of the child(ren) for whom you are applying. There is no limit on resources. Your monthly countable income cannot be more than the amounts listed below. Monthly Income Limits: Medicaid for Infants and Children (Effective April 2009) Family Size Age 0 - 5 Age 6 – 18 1 $1,805 $903 2 $2,429 $1,215 3 $3,052 $1,526 4 $3,675 $1,838 5 $4,299 $2,150 If your family income is greater than the amounts listed above, your child(ren) age 6-18 may be eligible for NC Health Choice for Children or Medicaid with a Medicaid deductible.
Medicaid for Families with Dependent Children Medicaid for Families with Dependent Children provides medical coverage for parent(s) or other caretaker/relative with child(ren) age 18 and under in the household and for children under age 21. A pregnant woman may also qualify. Your monthly countable income cannot be more than the amounts listed below. Monthly Income Limits: Medicaid Families with Dependent Children (Effective April 2009) Family Size 1 2 3 4
Caretakers and Children age 19 and 20 $362 $472 $544 $594
You cannot have more than $3,000 in assets such as savings in the bank. If the family income is over the limit and your child(ren) and/or family have high medical bills, you may still qualify for Medicaid and have a Medicaid deductible. Page | 15
Medicaid for Pregnant Women Medicaid for Pregnant Women only covers services related to pregnancy: • • • • •
Prenatal care, delivery and 60 days postpartum care. Services to treat medical conditions which may complicate the pregnancy.(some services require prior approval) Childbirth and parenting classes Family planning services Maternity Care Coordination services
A pregnant woman may apply for this program before or after she delivers. A woman who has experienced a recent pregnancy loss may also be eligible. The monthly family income cannot exceed 185% of the federal poverty level. There is no limit on resources. If a pregnant woman is covered by Medicaid on the date she delivers, her newborn child may be eligible for Medicaid up to age 1 without a separate application. Your monthly countable income cannot be more than the amounts listed below. Monthly Family Income Limits: Medicaid for Pregnant Women (Effective April 2009) Family Size Monthly Income Limit 2 $2,247 3 $2,823 4 $3,400 (The unborn child is always counted in the family size.)
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Community Alternatives Program for Children (CAP/C) What is CAP/C? The Community Alternatives Program for Children (CAP/C) (also known as the Katie Beckett waiver) provides home and community based services to medically fragile children who, because of their medical needs are at risk for institutionalization in a nursing home. Examples of children who may be eligible for CAP/C include children with ventilators, tracheostomies, feeding tubes, severe seizures, and those children who need help with activities such as bathing, dressing, grooming, and toileting when the child, for medical reasons, is not able to do or learn to do those tasks independently.
What Does CAP/C Cover? In addition to case management and in-home nursing or aide care, families may also receive some additional services and supplies that Medicaid would not ordinarily pay for. These include: • •
•
respite care (in-home or institutional nursing care provided in order to give the child’s caregiver some leisure time) home modifications (limited to stationary wheelchair ramps, widening of doorways for wheelchair access, and grab bars/safety rails mounted to the wall), and waiver supplies ( reusable diapers and the disposable liners for them).
Children on CAP/C also have access to regular Medicaid services, for example; physical therapy, occupational therapy, speech therapy, and medical equipment.
Who is Eligible? CAP/C is available to any child under 19 years of age who meets both the Medicaid eligibility criteria and the CAP/C criteria. The Medicaid criteria for CAP programs are not the same as the regular Medicaid criteria. Other criteria include that the child must live in a private residence, must be able to be cared for safely at home and meet minimum nursing facility level of care. The child’s needs must be able to be met within a monthly budget determined by the amount of care the child requires. The family must be willing to participate in the care and in the care planning for their child.
Contacts For more information about CAP/C services, call your local case management agency. Page | 17
Baby Love
The Baby Love program is a combination of services designed to help you have a healthy baby. Pregnant and postpartum women are eligible to receive these services. The program can help you and your baby from the beginning by providing: • • • •
maternity care coordination childbirth education classes counseling and emotional support when you feel stressed medical home visits for you and your baby conducted by qualified staff referrals to other programs like WIC, dental care, dietary evaluation and counseling, and family planning, including the Family Planning Waiver.
Child Service Coordinators (CSCs) can help with finding medical care, transportation, childcare and /or financial aid through a sub-program called Child Service Coordination. Children ages birth to three years who are at risk and children ages birth to five years who are diagnosed with developmental delay or disability, chronic illness or social/emotional disorder may be eligible for services through this program. More information about the Child Service Coordination Program
What is the Maternity Care Coordination Program? The Maternity Care Coordination Program (MCCP) is staffed by nurses, social workers, and paraprofessionals who help pregnant women and new mothers work on concerns that may affect the baby’s health. The MCCP can provide: • • • •
assistance in applying for Medicaid and health insurance coverage for other children referrals to community resources and agencies for housing, school, transportation, child care, etc. referrals to community agencies that provide information on pregnancy and newborn care resources to address issues that may cause you to feel stressed or worried.
No matter where you receive your prenatal care, you can sign up for the Maternity Care Coordination Program. Providers are located in every county in North Carolina. Page | 18
Health Check and EPSDT EPSDT and Health Check Information for Providers A federal law requires Medicaid to provide all medically necessary health care services to Medicaid-eligible children. This is called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). The services are required even if the services are not normally covered by children's Medicaid.
Who Is Eligible for Health Check and EPSDT? Medicaid-eligible children through the age of 20 are eligible for Health Check and EPSDT services. To find out if your child is eligible for Medicaid benefits, contact your local Department of Social Services (DSS). You will find them in the phone book under government agencies. You may go to the DSS to apply or ask them to send you an application in the mail. Applications are also available at the local health department. You may complete the application yourself and return it in person or mail it to the DSS.
Why are Health Check and EPSDT Important? Health Check and EPSDT are important because they: • •
provide early and regular medical and dental screenings for all Medicaid eligiblechildren identify treatments that are medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination.
What Treatment Services are Covered? Services must be ordered by the child's physician or another licensed clinician. Prior approval from the Division of Medical Assistance may be required to verify medical necessity for some services. The services must meet all of the conditions stated below: 1. The service must be medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination 2. The service must be listed in section 1905(a) of the Social Security Act. 3. The service cannot be experimental/investigational, unsafe or considered ineffective. Page | 19
Requests for Non-Covered Services If your child's physician or another licensed clinician determines that your child needs a treatment service that is not normally covered by Medicaid, they must request the service by writing to: Assistant Director for Clinical Policy and Programs Division of Medical Assistance 2501 Mail Services Center Raleigh, NC 27699-2501 Fax 919-715-7679
For More Information You can ask about Health Check, EPSDT services, and how to obtain medically necessary services not covered by N.C. Medicaid by contacting: • • • • •
your child's doctor a Health Check Coordinator (PDF, 177 KB) the contact number listed in your Health Check letters the local mental health program or any health care provider who accepts Medicaid.
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FORMS The most common forms for Medicaid and its’ associated programs are here including: • Medicaid Application • HealthChoice for Children Application • HealthChoice for Children Application (Spanish) • Medicaid Planning Waiver • Directory of NC Department Of Social Services Offices
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Application for Medicaid N.C. Department of Health and Human Services
This application is intended for medical assistance for the Aged, Blind and Disabled or those who want Family Planning services. A different application form is available for children and families who need Medicaid. Children under age 21 and adults with children in their care may be eligible for Medicaid without being blind, disabled or over age 65. You will need to list all family members who are applying for medical assistance. In addition, to ensure the applicants receive all possible assistance, list other persons in the home. Do not give us social security numbers, citizenship, or immigration status for these other persons. If you have questions about Medicaid programs for which you may be eligible, please contact the Department of Social Services and ask to speak with a Medicaid caseworker. Just mail or drop off the completed application at the department of social services in the county where you live. You can find address and phone number in your phone book under “County Government.” If you want to apply for Work First Family Assistance, Food Stamps, or Special Assistance (to pay for care in an Adult Care Home,) you must see a worker and complete an application at the Department of Social Services.
IMPORTANT NOTICE IF YOU CHOOSE TO PICK UP THIS APPLICATION AT THE DSS OFFICE: You or your representative have the right to make an application and have a face-to-face interview for Medicaid on the day you go into the Department of Social Services requesting medical or financial assistance. If you cannot stay to see a worker to apply for Medicaid, but you want a face-to-face interview, you can schedule an appointment. Please see the receptionist if you want to schedule an appointment. If you do not want a face-to-face interview and you complete an application and return it later, there is some information you should know: •
The date of your application is the date the Department of Social Services gets your completed application.
•
Medicaid coverage can be requested for any medical bills incurred up to three months prior to the month of application.
•
The date your Medicaid is started is based on the date of your application. If you wait until next month to return your complete application, Medicaid may not be able to help pay for medical services you received in earlier months.
•
If you are unable or need help to complete the application or obtaining requested information, contact the Department of Social Services and speak with a Medicaid caseworker.
•
You will receive a telephone follow-up call within two workdays.
DMA-5000 Rev. 6/09
Page 1 of 18
What is Medicaid? Medicaid is a health insurance program for those with income below amounts set by the federal and state government or with large unmet medical needs. Who can get Medicaid? ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Individuals or couples who are elderly (age 65 or older) Individuals who are visually impaired (blind) Individuals who need help in their home to care for themselves (CAP) Individuals who need help caring for themselves (nursing home or long-term care assistance) Individuals or couples who are physically or mentally disabled Individuals or couples who would like to receive family planning services Children under age 21 and adults with children in their care Pregnant Women
See page 3 for what the state of North Carolina considers to be disabled and a description of the CAP program. What will Medicaid pay for? Medicaid can help pay for certain medical expenses such as: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Doctor Bills Hospital Bills Prescriptions (Excluding prescriptions for Medicare beneficiaries effective 01/01/06) Vision Care Dental Care Medicare Premiums Nursing Home Care (LTC) Personal Care Services (PCS), Medical Equipment, and Other Home Health Services In home care under the Community Alternatives Program (CAP) Mental Health Care Most medically necessary services for children under age 21
Who can answer my questions about Medicaid? You can contact your local county department of social services, call the Medicaid Eligibility Unit through the toll free CARE-LINE, Information and Referral Service, at 1-800662-7030 or 1-877-452-2514 for the deaf or hearing impaired. The CARE-LINE is operational Monday through Friday (except state holidays) or visit DMA’s website at www.dhhs.state.nc.us/dma/. What is the Community Alternatives Program (CAP)? The Community Alternatives Program (CAP) allows some Medicaid recipients who require institutional care (placement in a hospital, nursing home, or ICF-MR), to remain at home if their care can be provided safely and at less expense in the community with CAP services. CAP participants must meet all CAP eligibility requirements. Page 2 of 18
How do I know if I am disabled? A disabled individual may be eligible for Medicaid if he is disabled according to the Social Security definition of disability. A child must meet Social Security’s childhood disability rules. If you are disabled you: ♦ Are unable to work for at least one year due to your medical problem, or ♦ Have a medical problem that may result in death. If you receive a Social Security (RSDI) or Supplemental Security Income (SSI) check because you are disabled you are automatically considered to meet the disability requirement for Adult Medicaid. Other individuals who apply for Medicaid and are over age 21, under age 65, and do not have children in their care, must be found to be disabled. This requirement does not apply to Family Planning Services only or to persons applying through the Breast and Cervical Cancer Control Program. How Do I Apply for Assistance? You will need to: ♦ Answer the questions in sections 1 through 15 in a legible manner. ♦ Sign the application. ♦ Bring or mail this application to your county department of social services (DSS) in the county where you live. If you need help locating your county DSS office, please call the DSS office, or CARE-LINE, Information and Referral Service, at 1-800-662-7030. ♦ Provide the needed items to complete your application. If you do not have all of the needed information and need help getting the information, return the application and ask your Medicaid worker at DSS for assistance. Once your application is received by your county department of social services, a case worker will call you to discuss your application in detail. What if I need help completing this application? Visit or call your county DSS. If you do not know where your county DSS is, call the toll free CARE-LINE, Information and Referral Service, at 1-800-662-7030 to find your county DSS. What do I do after I fill out this application? I fill out the application? ♦ Tear off pages 1 through 8 and keep them for your records. ♦ Be sure that you answer all questions in sections 1 through 15. ♦ Attach any documentation or verifications needed to process your application if you have them. ♦ Remember to sign and date page 18 because your application can not be processed without your signature. ♦ Bring or mail the Medicaid application to your county DSS.
Page 3 of 18
How long will it take to process my application? Once your application is received, we will begin processing it. ♦ If you are 65 or older or a child or caretaker of a child, it can take 45 days or less to process your application. ♦ If you are under age 65 and have no child in your care, it can take 90 days or less to process your application. If we need additional information, we will contact you by telephone or mail. The sooner we get the information, the sooner we can let you know if you can get Medicaid. What are My Rights? ♦ To apply for Medicaid, and, if found ineligible, you may reapply at any time. ♦ To apply for other assistance like Food Stamps or Work First Family Assistance. ♦ To have any person help you with this application or participate in the interview for determination of eligibility. ♦ To be protected against discrimination on the grounds of race, creed, or national origin by Title VI of the Civil Rights Act of 1964. ♦ To have any information given to the agency kept in confidence. ♦ To be given information by Social Services about Medicaid and other available assistance. ♦ To get assistance from the department of social services in completing this application or in getting information needed to process the application. ♦ To withdraw from the Medicaid program at any time. ♦ To receive assistance, if found eligible. ♦ To have your Medicaid considered under all categories. What Are My Responsibilities? ♦ To provide the county department of social services (DSS), as well as state and federal officials, upon request, the information necessary to determine eligibility. ♦ To report to the DSS any change in my situation within 10 calendar days of the change. ♦ To report to the DSS if I receive benefits in error. ♦ To agree by signing this form, that all information that I have provided is true and a complete statement of fact according to the best of my knowledge and that I understand that it is against the law to willfully withhold information or make false statements. I am subject to prosecution if I do. ♦ To understand that any Medicaid ID card I receive is to be used only for the persons listed on the ID card. I understand that it is against the law to give my ID card to someone whose name is not listed on it and that I may be prosecuted for fraud if I let someone else use my ID card. ♦ To understand that if any resources are transferred out of the applicant’s name without receiving fair market value for the resources, it could result in a period of ineligibility for long-term medical care, such as in a nursing facility, or for in-home care. I understand all transfer of resources must be reported when making this application and any new transfers must be reported to my worker within 10 calendar days. ♦ To understand any child or spousal support (money) which is paid directly to me must be reported to the county department of social services and will be counted as income when determining eligibility for Medicaid benefits for the person for whom it is received. ♦ North Carolina must be named remainder beneficiary for annuities purchased after November 1, 2007. Contact the county DSS for more information. Page 4 of 18
Medical Records I understand that my medical and financial records must be made available to the agency and the state by any provider from whom I have received medical care services. I hereby agree to the release of those records by those providers when requested by the agency and the state. The privacy of this information is protected by law. Assignment of Rights I understand that by accepting medical assistance, I agree to give back to the State any and all money that is received by me or anyone listed on this application from any insurance company for payment of medical and/or hospital bills for which the medical assistance program has or will make payment. I agree to assign the State of North Carolina as the Remainder Beneficiary of any annuities that I may have. In addition, I agree that all medical payments or medical support paid or owed due to a court order for me or anyone listed on this application must be sent to the State to repay past or current medical expenses paid by the state. This includes insurance settlements resulting from an accident. I further agree to notify the county department of social services if I or anyone listed on this application is involved in an accident. I understand that this assignment of rights continues as long as I or anyone listed on this application receive Medicaid and is based on federal regulations. Social Security Numbers I understand that I must furnish all social security numbers used by me to determine my eligibility for assistance if I am applying for myself. I understand that if anyone else wants to apply for assistance with me his social security number must be furnished. I also understand these social security numbers will be used in matching information with the Social Security Administration (SSA), Internal Revenue Service (IRS), Employment Security Commission (ESC), Department of Transportation (DOT), out of state welfare and ESC agencies, and any other agencies, when applicable. If I do not want these social security numbers used in the matches, I understand that I have the right to request my assistance to be denied, terminated or withdrawn. Estate Recovery Notice I understand that Federal and State laws require the Division of Medical Assistance (DMA) to file a claim against the estate of certain individuals to recover the amount paid by the Medicaid program during the time the individual received assistance with certain medical services. Ask your Medicaid case worker for specific information regarding which services are applicable to estate recovery. If You Request A Hearing If you do not agree with a decision we make about your case, you can request a hearing. You can request this in person, by telephone or in writing. You must ask for this hearing within sixty days of when we tell you in writing of our decision on your application. You have the right to examine your case record and documents used before your hearing. You can have a household member or someone you ask to represent you, like a friend or relative. You also have the right to have an attorney or other legal representative represent you at the hearing. Free legal aid may be available. Call 1-877-694-2464 for more information. Page 5 of 18
Residence I hereby certify under penalty of perjury that I and all the persons for whom I am making an application are living in North Carolina with the intention of remaining permanently or for an indefinite period or in the state seeking employment or have a job commitment. To verify North Carolina residency, provide two different documents from the following list: •
A valid North Carolina drivers’ license or other identification card issued by the North Carolina Division of Motor Vehicles.
•
A current North Carolina rent, lease, or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant’s legal spouse, showing a North Carolina address.
•
A current North Carolina motor vehicle registration in the applicant’s name and showing the applicant’s current North Carolina address.
•
A document verifying that the applicant is employed in North Carolina.
•
One or more documents proving that the applicant’s home in the applicant’s prior state of residence has ended, such as closing of a bank account, termination of employment, or sale of a home.
•
The tax records of the applicant or the applicant’s legal spouse, showing a current North Carolina address.
•
A document showing that the applicant has registered with a public or private employment service in North Carolina.
•
A document showing that the applicant has enrolled his children in a public or private school or a child care facility located in North Carolina.
•
A document showing that the applicant is receiving public assistance (such as Food Stamps) or other services which require proof of residence in North Carolina. Work First and Energy Assistance do not currently require proof of NC residency.
•
Records from a health department or other health care provider located in North Carolina which shows the applicant’s current North Carolina address.
•
A written declaration from an individual who has a social, family, or economic relationship with the applicant, and who has personal knowledge of the applicant’s intent to live in North Carolina permanently, for an indefinite period of time, or residing in North Carolina in order to seek employment or with a job commitment.
•
A current North Carolina voter registration card.
•
A document from the U.S. Department of Veteran’s Affairs, U.S. Military or the U.S. Department of Homeland Security, verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.
•
Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools (including secondary schools, colleges, universities, community colleges), verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or with a job commitment.
Page 6 of 18
•
A document issued by the Mexican consular or other foreign consulate verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.
*If you do not have two of these documents, contact the county DSS for assistance.
Citizenship, Identity and Immigration Status I understand that the person applying for non-emergency Medicaid must provide satisfactory proof of U.S. citizenship and identity if the applicant declares that they are a U.S. citizen or national. I understand that the person applying for non-emergency Medicaid may prove this by providing one of the following documents. • • •
U.S. Passport Certificate of Naturalization (N-550 or N-570) Certificate of Citizenship (N-500 or N-561) OR
You Need One From This List
AND
▼
You Need One From This List ▼
A U.S. Birth Certificate
A Driver’s License with a Picture
A Certification of Birth Issued by the Department of State (Form DS-1350)
A State Identity Document A School Identification Card with a Picture
A Report or Certification of Birth Abroad of a U.S. citizen (Form FS-240; FS-545)
A Military Dependent’s Identification Card with a Picture
Certification of Report of Birth (DS-1350) A U.S. Citizen I.D. card (DHS Form I-197 or I-179) Consular Report of Birth Abroad of a Citizen of the U.S. (FS545)
A Daycare or Nursery Record Showing Date and Place of Birth Government issued ID card Native American Tribal document
A Final Adoption Decree An Official Military Record of Service Showing U.S. Place of Birth (For Example, a DD-214)
NOTE: This does not list all acceptable documents. If you do not have documents to establish your identity, you may still be eligible. Contact a county DSS worker for assistance.
American Indian Card (I-872) NOTE: This does not list all acceptable documents. If you do not have these documents to establish your citizenship status, you may still be eligible. Contact a county DSS worker for assistance.
Non-applicant individuals applying for non-emergency Medicaid for someone else need not provide information about their U.S. citizenship or nationality. If not eligible for regular Medicaid, I understand that persons applying for Emergency Medicaid services only are not required to declare or provide proof of their citizenship status or Social Security Number. If the applicant is an alien, I also understand that the person applying for non-emergency Medicaid must provide proof of qualified alien status in order to receive non-emergency Medicaid. If the alien applicant has no documents to establish qualified alien status, contact a county DSS worker for assistance. If not eligible for regular Medicaid, I understand that persons applying for Emergency Medicaid services only are not required to declare or provide documentation of their immigration status or Social Security Number.
Page 7 of 18
MEDICAL TRANSPORTATION ASSISTANCE NOTICE OF RIGHTS The following information regarding medical transportation was explained to me. I understand that: •
If I receive Medicaid or have presumptive eligibility and do not have a way to get to the doctor or to other medical services, social services will help me arrange suitable transportation.
•
I can receive transportation assistance only after I am authorized for Medicaid or found to be presumptively eligible.
•
Medical transportation expenses that I am responsible for paying can be used to meet a deductible, including transportation expenses for anyone who is financially responsible for me.
•
I have the right to ask for help with transportation. I understand that if transportation is provided, it will be to the nearest appropriate medical provider of my choice, by the least expensive method suitable to my individual needs.
•
I, or someone acting on my behalf, may contact DSS by mail, phone, or in person to ask for help with transportation to the doctor or other medical services.
•
Except for emergencies, I must request transportation assistance as far in advance of my appointments as possible. Otherwise, my appointment(s) may have to be rescheduled.
•
I understand that I am not eligible for transportation assistance: if I am authorized for Medicare-Aid (M-QB); while my application is pending (before a decision is made) while I am on a deductible for Medicaid; OR while I am authorized for NCHC.
•
I have the right to a written notice of decision on my request within 10 work days, and I have the right to have a local conference to appeal the decision if I disagree.
NOTE:
You will need 2 first class stamps to mail this application. If you include additional information (pay stubs, bank statements, etc.) with the Medicaid application, additional postage may be needed. It is recommended that you verify with the post office the amount of postage needed.
*Tear off pages 1 through 8 and keep them for your records.
Page 8 of 18
For Official Use Only
Application for Adult Medicaid
County DSS: ________________________ Date Received:_______________________ Case #: _____________________________ DSS _______
Aging _______
Mail In________
North Carolina Department of Health and Human Services
I am applying for Medicaid for myself.
Yes
No
I am applying for Medicaid for my spouse.
Yes
No
I am age 65 or older.
Yes
No
My spouse is age 65 or older.
Yes
No
I am blind.
Yes
No
My spouse is blind.
Yes
No
I am disabled.
Yes
No
My spouse is disabled.
Yes
No
My child is disabled.
Yes
No
I am applying for Medicaid for a child or children in my care. List children below:
Yes
No
________________________ ____________ ____________ ________________________ Name DOB Sex Social Security Number
I need help with nursing home care.
Yes
No
My spouse needs help with nursing home care.
Yes
No
I am applying for the Community Alternatives Program (CAP).
Yes
No
My spouse is applying for the Community Alternatives Program (CAP).
Yes
No
My child is applying for the Community Alternative Program (CAP).
Yes
No
Medicaid Family Planning Waiver Services To be eligible for Medicaid Family Planning Waiver services, you must be a woman age 19 through 55 or a man age 19 through 60 and have not had a medical procedure that would prevent you from having a baby or fathering a baby. Do you wish to apply for Medicaid Family Planning Waiver?
Yes
No
If yes, for whom__________________________________Social Security #_________________
DMA-5000 Rev. 6/09
Page 9 of 18
1. Tell us about you. Applicant’s Name _____________________ _____________ ______________ ___________________________ First Middle Maiden Last
Social Security Number _______ - ______ - __________ (Not required if you are not applying for Medicaid for yourself, you are applying for Medicaid someone else, or you are applying for Emergency Medicaid.)
Please indicate your race(s)_____ Asian= A White or Caucasian = W Black or African American= B American Indian or Alaska Native= I Native Hawaiian or Other Pacific Islander= P ___________________________
Sex Male Female
Date of Birth ______ / ______ / _______ Month Date Year
Hispanic/Latino? Yes No
Do you speak English? Yes No
If yes, specify by circling the code below:
What language do you prefer to speak if not English?
Hispanic Cuban= C Hispanic Mexican= M Hispanic Puerto Rican= P Hispanic Other= H
________________________
I am a U.S. Citizen.
Yes Are you a Veteran? Yes No
No
(Not required if you are applying for Medicaid for someone else or emergency services.)
Have you served in the armed forces? Yes No
ARE YOU: Married Widowed Single Divorced Separated (When? ________)
If you live with your spouse:
(Please check only one box above)
Date of Birth:___________________ Sex:_____________
Spouse’s Name: _________________________________________________________ First Middle Maiden Last
Do you live with your spouse? Yes No Page 10 of 18
*Complete section 2 below, only if you want to apply for Adult Medicaid for your spouse. 2. Tell us about your spouse. Name _____________________ _____________ ______________ ___________________________ First Middle Maiden Last Sex Male Female
Date of Birth ______ / ______ / _______ Month Date Year
Please indicate your spouse’s race(s) ______
Hispanic/Latino? Yes No
Asian= A White or Caucasian = W Black or African American= B American Indian or Alaska Native= I Native Hawaiian or Other Pacific Islander= P __________________________ Is your spouse a Veteran? Yes No Has the spouse served in the armed forces? Yes No
If yes, specify by circling the code below:
Does your spouse speak English? Yes No What language does your spouse prefer to speak if not English?_________________
Social Security Number _______ - ______ - __________ (Not required if your spouse does not want Medicaid.)
Hispanic Cuban= C Hispanic Mexican= M Hispanic Puerto Rican= P Hispanic Other= H
My spouse is a U.S. Citizen Yes No (Not required if your spouse does not want regular Medicaid or if applying for emergency Medicaid.)
*Please provide documentation of citizenship, identity and/or qualified immigration status for any person applying for Medicaid. Persons applying for Emergency Medicaid services only are not required to provide documentation of citizenship or immigration status.
First
Middle
Last
Alien Registration Number Applicant Only
Does anyone live with you other than your spouse? Yes No If YES, Who? ______________________________ Relationship: _________________________ Who? ______________________________ Relationship: _________________________ Who? ______________________________ Relationship: _________________________ Page 11 of 18
3. Tell us where you live. Mailing Address (include apartment number, in care of, etc.) City, State, County, Zip Code
Home Phone (or number where you can be reached between 8am – 5pm)
Give the address where you actually live, if different than your mailing address: Do you live in a nursing home? If yes, please indicate the name of the home, city and phone number.
Name: City: Phone Number:
Do you and your spouse intend to remain in North Carolina?
Yes
No
4. Tell us about your dependents. Does anyone live with you and depend on you (or your spouse) to provide at least one-half of their financial support? Yes No If YES, Who? __________________________________________________________________ Relationship: __________________________________________Date of Birth_______________ 5. Tell us if you or your spouse have any unpaid medical bills. Do you, your spouse, or children need help paying medical bills for services received during the last three calendar months? Yes No If YES, please provide a copy of the medical bills from the last three months or fill out the information below. Do you, your spouse, or children have any old, unpaid (medical bills you have not paid yet) medical bills? ♦ The medical bills must be less than 2 years old, or ♦ If the medical bills are over 2 years old, you must have made a payment on them within the past 2 years. Yes No If YES, please provide us with a copy of the medical bills you are being billed for or fill out the information below. Bills used to meet a deductible will not be paid by Medicaid. *If you do not have copies of your medical bills, please fill out the chart below. Who owes the bill(s) Please give us the Patient’s name
List the name of the doctor, clinic, hospital, telephone number and city where treated.
Page 12 of 18
Date of medical treatment
6. Tell us if you, your spouse, or child need help with transportation to medical services. If you are found eligible for full Medicaid benefits, you have the right to assistance with medical transportation. Do you, your spouse, or child need help with transportation to medical services?
Yes
No
7. Tell us about you, your spouse’s, and your minor children’s income. Income refers to all the money that you, your spouse, and your minor children receive such as Social Security benefits, SSI benefits, retirement benefits, Veteran’s benefits, etc. If you (or your spouse or your children) if living together, receive income from any of the sources listed below, please enter the total monthly income. Do not list wages or self-employment. Type of Income: Social Security
Amount: Yes
No
$
Supplemental Security Income Veteran’s Benefits
Yes
No
$
Yes
No
$
Retirement Benefits
Yes
No
$
Railroad Retirement
Yes
No
$
Annuities
Yes
No
$
Civil Service
Yes
No
$
Pensions
Yes
No
$
Dividends/Interest Income from Trusts Income from Promissory Notes Disability Insurance
Yes
No
$
Yes
No
$
Yes
No
$
Support/Alimony
Yes
No
$
Land Lease Rentals
Yes
No
$
Rentals Roomers/Boarders Other
Yes
No
$
Yes
No
$
Who gets it:
How often:
Are you self-employed?
Yes
No
Do you have any Farm or Rental Income?
Yes
No
If YES, please attach last year’s income tax return or proof of your income and expenses for the past 12 months if you have that information.
Page 13 of 18
8. Tell us if you or your spouse work. . Tell us if you or your spouse work. Do you or your spouse work?
Yes
No
If YES, please complete the following chart. *List wages for you and your spouse (if your spouse lives with you and works) including Farm or Rental income. Name (who works)
Employer’s Name and Phone Number
Amount you earn before taxes (gross) $
How often are you paid?
Hours worked per week
$ $ $ *Please attach last month’s pay stubs or copies of them if you have that information. If you do not have this information, we will contact your employer for the information. 9. Does anyone give you or your spouse money? Does anyone give you cash or pay bills for you to help you or your spouse (if married and living together) pay for any of your household expenses including food, mortgage, rent, heating, fuel, gas, electricity, water, or property taxes? Yes No Do not include food stamps, help from a housing agency, an energy assistance program, or Meals on Wheels. Complete the chart below if you answered yes to the above question. *Please tell us who gives you money. Who receives the Help?
Who Gives You Help (name, address and phone number)
How much do you receive?
How often do you receive it?
$ $ $ $ $
Do you receive this help in the form of cash, check, or do they pay your bills directly? __________
Page 14 of 18
10. Tell us about you and your spouse’s assets. Assets are “What you own or are buying.” This can include: money in the bank, cash on hand, life insurance, real property (house or land) and personal property (car). Please complete the chart below. Indicate if you or your spouse (if married and living together) have any assets listed in the chart below. Include items that either of you own jointly or with another person.
Type of Account:
Owner
Account No. Bank/Company: Amount:
Cash
Yes
No
$
Checking
Yes
No
$
Savings
Yes
No
$
Money Market
Yes
No
$
Burial Contract
Yes
No
$
Safety Deposit Box
Yes
No
$
Certificates of Deposit Stocks
Yes
No
$
Yes
No
$
Trusts
Yes
No
$
Bonds
Yes
No
$
Mutual Funds
Yes
No
$
Annuities
Yes
No
$
401 K, Keough
Yes
No
$
Retirement Accounts Promissory Notes
Yes
No
$
Yes
No
$
Other Account
Yes
No
$
*Please attach copies of any information if you have them, to verify any assets you have listed.
Do you or your spouse own or are you buying any land, buildings, time-shares or jointly held real estate (heir property), including where you live? Yes No *If YES, list below: Owner/Owners or Buyer’s Names:
List address/location of what you own or are buying:
Page 15 of 18
*Do you or your spouse own any life insurance? Owner Company Name and Address (list name)
Policy Number
Face Value $
Cash Value
$
$
$
*Do you or your spouse own any of the following items in the chart below? Asset
Year
Make
Model
Owner (list name)
Value
Car
Yes
No
$
Car
Yes
No
$
Trucks
Yes
No
$
Boats
Yes
No
$
Campers
Yes
No
$
Motorcycles
Yes
No
$
Mobile Homes
Yes
No
$
Tractor/Trailers
Yes
No
$
Motorized Vehicles
Yes
No
$
Other – If additional space is needed, please attach the information to the application.
Yes
No
$
11. Tell us about any transfer of assets. Have you or your spouse transferred, given away or sold anything of value in the last 3 years or given money to a trust in the last 5 years? Yes No Examples of anything transferred, given away, or sold: cash, annuity, house, mobile home, car, tractor, livestock, motorized vehicles, land, time-shares or property.
*If Yes, please complete the chart on the next page.
Page 16 of 18
What did you or your spouse give away?
Value
To Whom?
Their relationship to you?
When?
$
How much did you receive? $
$
$
$
$
12. Tell us if you, your spouse, or your child have any health insurance, including Medicare. The provision of Social Security Numbers as insurance policy identifiers is voluntary for nonapplicant spouses or children. Do you have health insurance, Medicare or a Medicare HMO? Yes No If yes, which one(s) ______________________________________________________________ Medicare claim number: __________________________________________________________ Insurance company: _________________________________Policy number(s):______________ Policy Holder’s Name: ______________________Date of Birth: _______Relationship:_________ How much do you pay for private health insurance? ______________ How often? ____________ Does your spouse have health insurance, Medicare or a Medicare HMO? Yes No If yes, which one(s): _____________________________________________________________ Medicare claim number: __________________________________________________________ Insurance company: _______________________________Policy number(s):________________ Policy Holder’s Name: ______________________Date of Birth: _______Relationship:_________ How much does your spouse pay for private health insurance: __________ How often? ________ Do your children have health insurance? Yes No If yes, Name of Insurance Company: ___________________________Policy number: _________ Policy Holder’s Name _______________________Date of Birth: _______Relationship:_________ Are you or your spouse enrolled in a Prescription Drug Plan? Yes No If yes, please list the plan(s) you are enrolled with. ______________________________________ 13. Tell us if you, your spouse, or your child have been in any accidents. Have you, your spouse, or your child had an accident in the past 12 months?
Yes
No
14. Tell us if you need help paying your telephone bill or getting telephone service. The Lifeline/Link-up Assistance Program is for low-income individuals. The program serves recipients of the Food Assistance, Work First Family Assistance, Medicaid and Low Income Home Energy Assistance Programs, which includes the Low Income Energy Assistance Program, Crisis Intervention Program and Weatherization. Lifeline can help pay a portion of your local telephone bill. If you are eligible, Lifeline will give you a credit each month on your local telephone bill. Page 17 of 18
Link-Up is a program that can help pay to connect your telephone service. Do you or your spouse have telephone service in your name? Yes No If yes, in whose name(s) is the telephone bill? ________________________________________ What company provides your local telephone service? __________________________________ 15. Do you want us to contact someone else to complete this application? If you want us to contact someone else (family member, friend, representative, Power of Attorney or someone who knows your situation) to complete this application, please provide the person’s name, a daytime phone number, address, and their relationship to you. If we have additional questions, we will contact the person you list below to complete the application. Name:________________________________________________________________________ Address:_______________________________________________________________________ Telephone: ___________________ Relationship to (you) applicant(s): ______________________
Signature YOU MUST READ, SIGN AND DATE THIS PAGE. Your application for Medicaid cannot be processed without your signature.
I authorize the release of any information necessary to establish Medicaid and Lifeline/Link-up eligibility. I understand this information may include medical or non-medical information, including such collateral sources as banks, employers, and insurance companies. This authorization may be reproduced and is valid for one year from the date of signature. I understand social security numbers are used to do computer matches with the Internal Revenue Service, the Social Security Administration, Department of Labor, other government agencies and private financial institutions. The Department of Health and Human Services and federal officials may check with people to prove the information I have given. If I give incorrect information, my application may be denied and I may be charged with giving false information. I understand the questions on this form. I certify, under penalty of perjury, that all my answers are correct and complete as far as I know. I understand the Department has the right to collect from other available insurance sources or from settlement(s) for accidents or injuries when Medicaid paid for expenses. Signature of Applicant or Person Signing on Behalf of Applicant: __________________________________________________________Date: _____________________________
Home Phone Number: ___________________________________ OR
Signature of person filling out this form (if not applicant):_____________________________ Relationship: ___________________________________Home Phone Number:______________________ Page 18 of 18
HEALTH CHECK / NC HEALTH CHOICE FOR CHILDREN APPLICATION
Better health for you and your children, peace of mind for you. Free or Low-Cost Health Insurance (Pregnant women, parents, or other adults may also use this application to apply for Medicaid as a caretaker or for Family Planning Services.) Si usted desea obtener la forma DMA-5063, solicitud en español para seguro medico para niños, comuníquese con el departamento de servicios sociales de su localidad. También puede llamar a la línea de Recursos de Salud Familiar al 1-800-367-2229. Se le atenderá en español. (You can get a Spanish application at your local department of social services or call 1-800-367-2229.)
WHAT ARE HEALTH CHECK AND NC HEALTH CHOICE FOR CHILDREN? Health Check (the Medicaid Insurance Program) and Health Choice are two similar health insurance programs. Your family’s income, the number of people in your family and the age of the children determine if you or your children qualify. This information will also be used to determine in which program you or the children will be enrolled.
WHAT ARE THE BENEFITS? •Sick visits •Checkups •Hospital care
•Counseling •Prescriptions •Dental care
•Eye exams and glasses •Hearing exams and hearing aids •And more!
Transportation - If you or your children are enrolled in Health Check, transportation to medical appointments may be provided through your department of social services. If the children are enrolled in Health Choice, you must provide your own transportation. Children with Special Health Care Needs may be eligible for additional services.
HOW DO I APPLY? It's easy. Just mail or drop off the completed application at the department of social services in the county where you live. If you would like help filling out the application, call or visit your department of social services. You can find the address and phone number in your phone book under “County Government” or by calling the North Carolina Family Health Resource Line at 1-800-367-2229. Be careful to answer all the questions completely so we can process your application more quickly. If you need more space, please attach additional pages. It can take 45 days or less to process your application. If we need additional information, we will contact you by mail. The sooner we get the information, the sooner we can let you know if your children qualify. DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 1
WHAT ELSE DO I NEED TO KNOW ABOUT HEALTH CHECK AND HEALTH CHOICE? Will My Children Get Insurance Cards?
Will I Have to Pay Enrollment Fees and a Co-pay?
YES! Your children will receive insurance cards in the mail. Please keep the card handy so you can show it at medical appointments and when you fill prescriptions.
How Do I Choose a Doctor?
Depending on your income, you may have to pay an enrollment fee of $50 to $100 per family per year. In some cases, you also may have a small co-pay for doctor visits and prescriptions. If the fee and/or co-pay apply to you, you will be notified.
The department of social services will help you choose your doctor.
Will My Children Be Enrolled Immediately?
Will I Need to Re-enroll ? YES! You will need to re-enroll to continue benefits. For most children this is done once a year. You will be contacted when it is time to re-enroll.
Health Check (the Medicaid Insurance Program) has no funding limits, so there is no waiting list. If your children are eligible for Health Choice, they may have to go on a waiting list before being enrolled if federal or state funds are not sufficient to serve more children.
WHAT ARE MY RESPONSIBILITIES? 3
You agree to tell the department of social services within 10 days if there are any changes in the information you provided on your application.
3
A state or federal reviewer may check the information on this form. You agree to participate in the review and will cooperate with the reviewer.
3
If you knowingly provide false information or if you withhold information and you or your children get health insurance for which they are not eligible, you can be lawfully punished for fraud and may be asked to repay the programs for any medical bills and/or premiums that were paid incorrectly.
3
You agree to tell the department of social services if anyone with Health Check (the Medicaid Insurance Program) is in an accident.
If Health Check (the Medicaid Insurance Program)/Health Choice pays for health care for you or your children, you give permission to the state of North Carolina to collect payments from anyone who is supposed to pay for that care. You also agree to share medical information about your children with any insurance company to get the medical bills paid.
3
For a person to be enrolled in Health Check (the Medicaid Insurance Program)/Health Choice, you must provide his/her social security number or apply for a number. Please know that these numbers will be matched by computer with other government agency records (but not the Bureau of Citizenship and Immigration Services) to verify information. If you decide not to give the numbers, the person cannot be enrolled.
3
For Health Check, provide proof of identity and U.S. citizenship or information for the county DSS to obtain the proof for those applying for benefits. For refugees and legally qualified immigrants, provide proof of legal status for those applying.
WHO CAN ANSWER MY QUESTIONS?
WHAT ARE MY RIGHTS? 3
3
Health Check (the Medicaid Insurance Program)/Health Choice cannot Contact the department of social services in the county discriminate on the basis of race, color, nationality, sex, religion, age, where you live or call the NC Family Health Resource disability in employment or the provision of services.
Line at 1-800-367-2229.
3
By law, all information that you provide remains private.
3
You can ask for a hearing if you think any decisions are unfair, incorrect or are made too late.
Before you return the application, please make sure to do the following: Read pages 1 and 2. Tear them off and keep for your records. Complete the questions on pages 3 through 6. Sign the application on page 5. DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 2
For Office Use Only County DSS: _____________________ Date Received: ____________________ Case #: __________________________
Mail in
DSS
Health Dept
APPLICATION Please complete. Then send pages 3-6 to your local department of social services. If this application is being completed by or for a pregnant woman who has no other children living with her or you are applying for Family Planning, complete this application as if the pregnant woman or you is already a parent.
Tell Us About the Family 1. Who are all the children under age 21 who live in the home? Fill out this information even for children who will not be applying for Health Check/Health Choice. Social Security number, proof of identity, and citizenship status are required only for those applying for Health Check. Applying for this child (Y, N)
Name of child (first, middle initial, last)
*Asian= A
American Indian or Alaska Native= I
** Hispanic Puerto Rican= P
Hispanic Mexican= M
*Race (Use codes below. List all that apply.)
**Hispanic/Latino (Y, N) If yes, specify using codes below.
Caucasian or White= W
Is Child a U.S. citizen? (Y, N)
Social Security Number (SSN)
Black or African-American= B
Hispanic Other= H
(If different, please put your address on a separate sheet and return with this application.)
Address:
Mailing address (if different):
City:
State:
Home phone: (
Sex (M, F)
Native Hawaiian or other Pacific Islander= P
Hispanic Cuban= C
2. Where do you & the children live?
Date of birth (mo/day/yr)
Zip Code:
City:
)
Daytime phone: (
State:
Zip Code:
)
3. Who are the parents living with the children? If the children do not live with their parents, who are the adults living in the home who care for the children? Name of parent or adult (first, middle initial, last)
Date of birth (mo/day/yr)
Sex (M, F)
*Race (Use codes in 1. above. List all that apply.)
**Hispanic/Latino (Y, N) If yes, use codes in 1. above.
Children’s names and parent or adult relationship to the children (John – Mother, Mary - Stepmother)
a. Do you want to apply for pregnancy coverage for any of the people listed in #3 above?
Yes
No If you are applying for pregnancy assistance, you need to provide a statement from the doctor that includes the delivery date and the number of babies expected. However, send in the application form even if you do not have the statement from the doctor yet. If yes, for whom? ____________________________________Relationship:______________________SSN__________________ b. Do you want to apply for Medicaid for any of the people listed in #3 above? If you want to apply, you will be contacted for information about bank accounts, real and personal property, cash value of life insurance, stocks, bonds, etc. The total of these must be less than $3,000. Also, if you are eligible, you may be responsible for some of your medical bills.
Yes
No Applicants must provide their Social Security numbers and may have to give information to the child support office. If yes, for whom: _____________________________________Relationship:______________________SSN_________________ c. Do you want to apply for family planning services for any people ages 19 and older listed above?
Yes
No Applicants must provide their Social Security numbers. If yes, for whom: _____________________________________Relationship:______________________SSN_________________ DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 3
4. Is there a family member living away from the home for less than 12 months (Example: military service, attending school)?
Yes
No If yes, please give information below: Full name (first, middle initial, last)
Relationship
Reason for absence
Expected date of return
Tell Us About the Family’s Health Insurance and Medical Needs 5. Is there currently a parent not living in the home?
If yes, what is that parent’s name? (optional) Is that parent required by an agreement to pay for health insurance? 6. Does anyone applying have another health insurance plan? If yes, please give information below: Name of Insured (first, middle initial, last)
Owner of Policy
Insurance Company Name
Yes
No
Yes
No
Insurance Company Address
7. Does anyone applying need help paying medical bills from the past three months? If yes, please give the information below: We may be able to help pay those bills. Name of person(s) with bill (first, middle initial, last)
Yes
No
Insurance Company Phone Number
Group/Policy Number
Yes
No
Name of doctor, clinic and/or hospital where person was treated
Date of medical treatment
8. Has anyone applying been in an accident in the past 12 months?
Yes
No Did he/she receive medical care because of the accident?
Yes
No If yes, please tell us who. _______________________________________ When was the accident? ______/________/________ Tell Us About the Parent’s and Children’s Income 9. Who are the parents and children in the home who work, and what are their wages? Name of working person (first, middle initial, last)
Employer's name and phone number
Amount earned before deductions
$ $ $
Tips earned
How often paid (monthly, weekly, etc.)
$ $ $
Please provide copies of all of last month’s paycheck stubs for everybody listed. Send in the application even if you do not have your stubs. 10. Is there a parent or child in the home who is self-employed?
Yes
No For example, does anyone earn money from farming, own his or her own business, or have rental property income? If yes, please attach business records showing income and expenses for the last 6 months or the number of months in business if less than 6 months. If the income is annual, please attach business records for the last 12 months. 11. Has a parent or child in the home lost a job in the past three months? If yes, please complete the following: Name of person(s) who lost a job
DMA-5063 (04-2007)
Date job lost
Former employer’s name
Yes
No
Former employer's address & phone number
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 4
12. If the parent or child receives income from any other source please complete the blocks below. Type of income
Name of the person who receives other income
Amount received
Child Support:
$
Social Security:
$
Unemployment:
$
Other (Please explain):
$
How often received (monthly, weekly, etc.)
Tell Us About the Parent’s and Children’s Expenses Some of these expenses may be used to reduce the income that we count to determine enrollment in Health Check/Health Choice. 13. Does a working parent living in the home pay for childcare, a babysitter or care for dependent adult? If yes, please fill in the information: Name, address & phone number of sitter or childcare provider
Name of person cared for
Name of person paying for care
Yes
No
Amount paid
How often paid (monthly, weekly, etc.)
$ $ 14. Does a parent living in the home pay child support for a child who is not living in the home? If yes, please fill in the information. Who pays the support & to whom
For whom is the support paid
Is it court ordered (Y, N)
Yes
No
Amount paid
Please Attach Verification
How often paid (monthly, weekly, etc.)
$ $ Tell Us If You Would Like Help With Child Support The Child Support Agency can help get financial and medical help for the child from the child’s absent parent. If you seek assistance from the Child Support Agency, the courts can establish paternity and establish and enforce medical support obligations. There are other benefits to working with the Child Support Agency. For example, your child may be eligible for other financial benefits, including Social Security, pension benefits, veteran’s benefits and possible inheritance. Also, your child may benefit by having a bond between parent and child. Finally, your child may benefit by getting important medical history information. If you want the Child Support Agency’s help in establishing paternity or in getting a medical support order through the court, check the “Yes” box. If you check the box, someone will contact you.
Yes, I would like help from the Child Support Agency. 3 3 3 3 3 3
I attest that all statements recorded on this document are true and correct to the best of my knowledge. I have either read or had read to me all attachments to this application, and I understand my rights and responsibilities as an applicant/recipient. I authorize the release of any information necessary to establish my family's eligibility. I understand that this information may include medical information about the individuals applying for health insurance and/or nonmedical information about individuals applying and others. This might include information from doctors, hospitals, employers and insurance companies. I have received or understand that I will receive a copy of the “Medicaid Notice of Privacy Practices.” I authorize the copying of this release form to verify information. It shall remain valid and in force until revoked by me in writing. I understand that if Medicaid pays for nursing facility care, in-home health services, or services provided under the Community Alternatives Program (CAP), Medicaid may become a creditor of my estate and my estate may be subject to recovery to repay Medicaid.
Signature of parent or other adult: 9__________________________________________________ Date: ________________________ DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 5
Language Preference and Special Needs (Optional) You may still apply for Health Check/Health Choice even if you don’t answer the questions on this page.
What Language Does the Family Prefer to Speak? The federal government requires the State to provide information about the languages the family speaks. Please help us by providing the information for the parent/other adult living in the home. Name of person (first, middle initial, last)
Language person prefers to speak (circle one)
1.
English
Spanish
Other (Specify______________________________)
2.
English
Spanish
Other (Specify______________________________)
3.
English
Spanish
Other (Specify______________________________)
4.
English
Spanish
Other (Specify______________________________)
5.
English
Spanish
Other (Specify______________________________)
6.
English
Spanish
Other (Specify______________________________)
Does Your Child Have Special Health Care Needs? Please help us improve services for children with special health care needs and meet federal reporting requirements by answering these questions. The answers will not affect your child’s eligibility for Health Check or NC Health Choice. 1. Do any of your children currently need medicine prescribed by a doctor other than vitamins?
Yes
No If yes, does your child (or children) need this medicine because of any medical, behavioral or other health condition that
Yes
No has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children):____________________________________________________________________ 2.
Do any of your children need more medical care, mental health or education services than usual or routine for most children of the same age?
Yes
No If yes, does your child (or children) need these services because of any medical, behavioral or health condition
Yes
No that has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children): ______________________________________________________________________________________________________________
3.
Are any of your children limited or prevented in any way in their ability to do the things most children their age can do?
Yes
No If yes, is this limitation because of any medical, behavioral or health condition that has lasted or is expected
Yes
No to last at least 12 months? If yes, please list the name of the child (or children): ____________________________________________________________________
4.
Do any of your children need special therapy, such as physical, occupational, or speech therapy?
Yes
No If yes, does your child (or children) need this therapy because of any medical, behavioral or other health condition that
Yes
No has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children):_____________________________________________________________________
5.
Do any of your children currently have any kind of emotional, developmental or behavioral difficulty for which they need treatment or counseling?
Yes
No If yes, does your child (or children) need this treatment or counseling because of any medical, behavioral or other
Yes
No health condition that has lasted or is expected to last at least 12 months? If yes, please list the name of your child (or children):____________________________________________________________________
DID YOU SIGN THE APPLICATION ON PAGE 5? DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 6
SOLICITUD DEL PROGRAMA HEALTH CHECK / NC HEALTH CHOICE PARA NIÑOS
Mejor salud para usted y sus hijos, tranquilidad de espíritu para usted. Seguro de salud de bajo costo o sin cargo (Mujeres embarazadas, padres, madres, u otros adultos pueden también utlizar esta solicitud para solicitar la inscripción en Medicaid como persona a cargo de prestar cuidados o para Servicios de planificación familiar.) Si usted desea obtener el formulario DMA-5063, solicitud en español para seguro médico para niños, comuníquese con el Departamento de Servicios Sociales de su localidad. También puede llamar gratuitamente a la Línea de Recursos de Salud Familiar al 1-800-367-2229. Se le atenderá en español. (Puede obtener una solicitud en español en el Departamento de Servicios Sociales local o llamar al 1-800-367-2229.)
¿QUÉ ES EL PROGRAMA HEALTH CHECK Y EL NC HEALTH CHOICE PARA NIÑOS? Health Check (el Programa de seguro Medicaid) y el Health Choice son dos programas de seguro de salud similares. Los factores que determinan si usted o sus hijos pueden acceder a ellos son: los ingresos familiares, la cantidad de miembros de la familia y la edad de los hijos. Esta información también se utilizará para determinar a cuál programa se inscribirán usted o sus hijos. ¿CUÁLES SON LOS BENEFICIOS? •Consultas por enfermedad •Chequeos rutinarios •Atención en el hospital
•Asesoramiento •Recetas •Atención odontológica
•Exámenes de la vista y anteojos •Exámenes de la audición y dispositivos auditivos •¡Y más!
Transporte – Si usted o sus hijos están inscritos en Health Check, es posible que el departamento de servicios sociales le podrá brindar el transporte a las visitas médicas. Si los niños están inscritos en Health Choice, usted debe disponer de su propio transporte. Los niños con necesidades de atención de salud especiales pueden ser elegibles para recibir servicios adicionales.
¿CÓMO SOLICITO EL BENEFICIO? Es fácil. Simplemente llene la solicitud y envíela por correo, o llévela al departamento de servicios sociales del condado en el que vive. Si desea ayuda para llenar la solicitud, diríjase al Departamento de Servicios Sociales de su localidad o llame por teléfono. Puede encontrar la dirección y el número de teléfono en las páginas azules de su directorio telefónico bajo “County Government” (“Gobierno del condado”) o llamando gratis a la Línea de Recursos de Salud Familiar de Carolina del Norte al 1-800-367-2229. Asegúrese responder todas las preguntas completamente de manera que podamos procesar su solicitud más rápidamente. Si necesita más espacio, adjunte páginas adicionales. El proceso de su solicitud puede demorar 45 días como máximo. Si necesitamos información adicional, nos comunicaremos con usted por correo. Mientras antes recibamos la información, antes podremos informarle si sus hijos cumplen con los requisitos.
DMA-5063 (04-2007)
¿Tiene alguna pregunta sobre Health Check / Health Choice? Llame al 1-800-367-2229.
Página 1
¿QUÉ MÁS DEBO SABER SOBRE HEALTH CHECK Y HEALTH CHOICE? ¿Obtendrán mis hijos tarjetas del seguro? ¡SÍ! Sus hijos recibirán tarjetas del seguro por correo. Mantenga la tarjeta a mano de manera que la pueda mostrar en las consultas médicas y para sus recetas médicas. ¿Cómo puedo elegir a un médico? El departamento de servicios sociales le ayudará a escoger a su médico. ¿Es necesaria la reinscripción? ¡SÍ! La reinscripción es necesaria para continuar recibiendo beneficios. Para la mayoría de los niños esto se hace una vez al año. Nos comunicaremos con usted cuando sea momento de reinscripción.
¿Tendré que pagar tarifas de inscripción y un copago? Dependiendo de sus ingresos, es posible que tenga que pagar una tarifa de inscripción de $50 a $100 por familia al año. En algunos casos, también es posible que tenga que pagar un pequeño copago por visitas al médico y por recetas. Si le corresponde pagar la tarifa o el copago, se le informará al respecto. ¿Serán inscritos inmediatamente mis hijos? Health Check (el Programa de seguro Medicaid) no tiene límites de provisión de fondos, así que no existe lista de espera. Si sus hijos cumplen con los requisitos de Health Choice, es posible que queden en una lista de espera antes de ser inscritos si no hay fondos estatales o federales suficientes para atender a más niños.
¿CUÁLES SON MIS RESPONSABILIDADES? 3
Acepta informarle al departamento de servicios sociales en un plazo de 10 días si se presenta cualquier cambio en la información que dio en su solicitud.
3
Un revisor estatal o federal puede revisar la información en este formulario. Acepta participar en la revisión y cooperará con el revisor.
3
Si usted brindó información falsa a sabiendas o si usted retuvo información y usted o sus hijos reciben cobertura de salud para la cual no reúnen los requisitos necesarios, usted puede ser castigado legalmente por fraude y se le puede exigir que les reembolse a los programas cualesquiera de las cuentas y/o primas médicas que hubieren sido pagadas incorrectamente.
3
Acepta informarle al departamento de servicios sociales si cualquiera inscrito en Health Check se encuentra en un accidente.
3
Si Health Check (el Programa de seguro de Medicaid) / Health Choice paga los gastos médicos de usted o de sus hijos, usted autoriza al estado de Carolina del Norte a recibir los pagos de cualquier persona que se supone pague dicho gasto. También acepta compartir información médica sobre sus hijos con cualquier compañía de seguros para fines del pago de las cuentas médicas.
3
Para que una persona esté inscrita a Health Check / Health Choice, usted debe indicar su número de seguro social o solicitar un número (sólo para la persona por la cual se está solicitando). Tenga presente que estos números se compararán por computadora con los registros de otros organismos gubernamentales (pero no la Oficina de Servicios de Ciudadanía e Inmigración) para verificar la información. Si decide no dar los números, la persona no se podrá inscribir.
3
Para Health Check, presente prueba de identidad y de ciudadanía de EE.UU. o presente información al Departamento de Servicios Sociales del condado para obtener la prueba para los que solicitan los beneficios. Para los refugiados e inmigrantes documentados, presente prueba de estado civil de los que solicitan los beneficios.
¿QUIÉN PUEDE RESPONDER MIS PREGUNTAS?
¿CUÁLES SON MIS DERECHOS? 3
Health Check (el Programa de seguro Medicaid) / Health Choice no pueden discriminar en base de raza, color, nacionalidad, sexo, religión, edad, discapacidad en el empleo o la prestación de servicios.
3
Por ley, toda información que proporcione permanece privada.
3
Puede pedir una audiencia si cree que alguna decisión es injusta, incorrecta o se toma demasiado tarde.
Póngase en contacto con el departamento de servicios sociales del condado donde usted vive, o llame gratuitamente a la Línea de Recursos de Salud Familiar al 1-800-367-2229.
Antes de entregar la solicitud, por favor, asegúrese de hacer lo siguiente: Lea las páginas 1,2 y 3. Despréndalas y guárdelas para su registro. Complete las preguntas de las páginas 4 a 6. Firme la solicitud en la página 5.
DMA-5063 (04-2007)
¿Tiene alguna pregunta sobre Health Check / Health Choice? Llame al 1-800-367-2229.
Página 2
For Office Use Only County DSS: _____________________ Date Received: ____________________ Case #: __________________________
Mail in
DSS
Health Dept
SOLICITUD
Complete esta solicitud. Luego envíe las páginas 4 a 6 al Departamento de Servicios Sociales de su localidad. Si quien completa esta solicitud es o representa a una mujer embarazada que no tiene otros hijos viviendo con ella, o usted está presentando la solicitud para Planificación familiar, complete esta solicitud como si la mujer embarazada o usted ya fueran padres. Infórmenos sobre la familia 1. ¿Quiénes son todos los hijos menores de 21 años que viven en el hogar? Llene esta información incluso para los hijos que no solicitarán Health Check / Health Choice. requieren sólo para quienes solicitan Health Check. Solicita Nombre del hijo para Fecha de Sexo (primer nombre, inicial del segundo, apellido) este hijo nacimiento (M, F) (S, N) (mes/día/año)
El número del Seguro Social, la prueba de identidad y el estado de ciudadanía se *Raza (Use los códigos que aparecen más abajo. Indique todo lo que le corresponda.)
** ¿Hispano o latino? (S, N) Si la respuesta es Sí, especifique usando los códigos que aparecen más abajo.
¿El hijo es ciudadano de los EE.UU.? (S, N)
Número del Seguro Social (SSN)
*Asiático = A Indio americana o nativa de Alaska = I Nativo de Hawai o de otra isla del Pacífico = P Caucásico o Blanco = W Negro o afroamericano = B ** Hispano de Puerto Rico = P Hispano de Cuba = C Hispano de México = M Hispano de otro país = H 2. ¿Dónde viven usted y sus hijos? (Si viven en lugares diferentes, ponga su dirección en una hoja separada y devuélvala con esta solicitud.) Dirección:
Dirección postal (si fuera diferente):
Ciudad: Teléfono particular: (
Estado: )
Código postal:
Ciudad:
Teléfono durante el día: (
Estado:
Código postal:
)
3. ¿Quiénes son los padres que viven con los hijos? Si los hijos no viven con sus padres, ¿quiénes son los adultos que viven en el hogar y que cuidan a los hijos? Nombre del padre, madre o adulto (primer nombre, inicial del segundo, apellido)
Fecha de nacimiento (mes/día/año)
Sexo (M, F)
*Raza (Use códigos usados arriba. Indique todo lo que le corresponda.)
** ¿Hispano o latino? (S, N) Si la respuesta es Sí, use código usado arriba.
Nombres de los hijos y relación de los padres o adultos con ellos (madre de Juan, madrastra de Maria)
a. ¿Desea solicitar cobertura de embarazo para alguna de las personas mencionadas en el Nº 3 anterior?
Sí
No Si está solicitando ayuda para el embarazo, debe proporcionar una declaración del médico que incluya la fecha de parto y el número de bebés que espera. De todos modos, envíe un formulario de solicitud si aún no tiene la declaración del médico. Si la respuesta es Sí, ¿para quién? ___________________________________Relación:______________________ SSN (Nº de seguro social)__________________ b. ¿Desea solicitar Medicaid para alguna de las personas mencionadas en el Nº 3 anterior? Si desea solicitarlo, nos pondremos en contacto con usted para solicitarle información sobre ingresos, cuentas bancarias, bienes muebles e inmuebles, valores en efectivo de seguro de vida, acciones de capital, bonos, etc. Los recursos totales no deben superar los $3000.
Además, aunque usted reúna los requisitos para poder acceder a estos beneficios, es posible que deba pagar alguna de sus cuentas médicas.
Sí Los solicitantes deben dar su número de Seguro Social y es posible que tengan que dar información a la Oficina de Sustento (Manutención) de Niños. Si la respuesta es Sí, para quién desea solicitar Medicaid: ________________________________Relación:__________________ SSN (Nº de seguro social)__________________ c. ¿Desea solicitar servicios de planificación familiar para alguna persona de 19 años o más mencionada anteriormente? Los solicitantes deben dar su número de Seguro Social. Si la respuesta es Sí, para quién: ___________________________________Relación:______________________ SSN (Nº de seguro social)__________________
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Sí
No
No
Página 3
4. ¿Algún integrante de la familia vive lejos del hogar durante menos de 12 meses (ejemplo: servicio militar, escuela)? Si la respuesta es sí, proporcione la información a continuación: Nombre completo (primer nombre, inicial del segundo, apellido)
Relación
Sí
No
Motivo de la ausencia
Fecha programada de regreso
Infórmenos sobre el seguro de salud y las necesidades médicas de la familia 5.
¿Alguno de los padres no vive actualmente en el hogar?
Si la respuesta es Sí, ¿cuál es el nombre de dicho padre/madre? (opcional) ¿Algún acuerdo exige que dicho padre/madre pague el seguro de salud? 6.
¿Alguno de los solicitantes tiene otro plan de seguro de salud? Si la respuesta es sí, proporcione la información a continuación: Nombre del asegurado (primer nombre, inicial del segundo, apellido)
Titular de la póliza de seguro de salud
Nombre de la compañía de seguros
Dirección de la compañía de seguros
8.
No
Sí
No
Sí
No
Número de teléfono de la compañía de seguros
7. ¿Alguno de los solicitantes necesita ayuda para pagar cuentas médicas de los últimos tres meses?
Sí Si la respuesta es sí, proporcione la información a continuación: Podríamos ayudarle a pagar esas cuentas. Nombre de la/s persona/s con la cuenta (primer nombre, inicial del segundo, apellido)
Sí
No
Nombre del médico, clínica u hospital en donde se trató a la persona
¿Alguno de los solicitantes ha estado en un accidente en los últimos 12 meses? ¿Recibió esta persona atención médica debido al accidente? Si la respuesta es Sí, infórmenos quién. _______________________________________ ¿Cuándo fue el accidente? ______/________/________
Sí
Número de grupo / póliza
No
Sí
Fecha del tratamiento médico:
No
Infórmenos sobre los ingresos de padres e hijos 9. ¿Quiénes son los padres e hijos en el hogar que trabajan y cuáles son sus salarios? Nombre de la persona que trabaja (primer nombre, inicial del segundo, apellido)
Nombre y número de teléfono del empleador
Monto bruto de ingreso (durante cada periodo de pago) $
Propinas ganadas $
$
$
$
$
¿Con qué frecuencia cobra? (mensual, semanal, etc.)
Proporcione copias de todos los comprobantes de sueldo del último mes de todas las personas mencionadas. Envíe la solicitud incluso si no tiene sus comprobantes.
10. ¿Alguno de los padres o de los hijos del hogar actualmente trabaja por su propia cuenta?
Sí
No Por ejemplo, ¿alguno gana dinero de la agricultura, tiene su propio negocio o recibe ingresos por el alquiler de una propiedad? Si la respuesta es Sí, adjunte registros comerciales que muestren ingresos y gastos durante los últimos 6 meses, o el número de meses en la actividad comercial si es inferior a 6 meses. Si el ingreso es anual, adjunte registros comerciales de los últimos 12 meses.
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Página 4
11.
¿Alguno de los padres o hijos del hogar perdió el empleo en los últimos tres meses? Si elige Sí, por favor proporcione la siguiente información: Nombre de la(s) persona(s) que perdió (perdieron) el empleo
12.
Fecha de pérdida del empleo
Nombre del ex-empleador
Si el padre o hijo recibe ingresos de cualquier otra fuente, llene las siguientes casillas. Tipo de ingreso
Sí
No
Dirección y número de teléfono del ex-empleador
Nombre de la persona que recibe otros ingresos
Monto recibido
Sustento de hijos:
$
Seguro social:
$
Beneficios por desempleo: Otros (explique):
$ $
Con qué frecuencia se recibe (mensual, semanal, etc.)
Infórmenos sobre los gastos de padres e hijos Algunos de estos gastos se pueden usar para reducir el ingreso que consideramos para determinar la inscripción a Health Check / Health Choice.
13.
¿Alguno de los padres que trabaja paga una guardería, una niñera o un cuidador para un adulto a su cargo? Si la respuesta es Sí, proporcione la información a continuación: Nombre, dirección y número de teléfono de la niñera o del proveedor de cuidado infantil
Nombre de la persona a quien se cuida
Sí
No
Nombre de la persona que paga el cuidado
¿Cuánto paga?
Con qué frecuencia paga (mensual, semanal, etc.)
$ $ 14. ¿Alguno de los padres que vive en el hogar paga el sustento de menores de algún hijo que no vive en el hogar? Si la respuesta es Sí, proporcione la información a continuación: Quién paga el sustento y a quién
Para el beneficio de quién se paga el sustento
Sí
¿Es por sentencia judicial? (S, N)
No
¿Cuánto paga? Por favor, adjuntar verificación
Con qué frecuencia recibe pago (mensual, semanal, etc.)
$ $ Infórmenos si desea ayuda con la manutención de sus hijos La Agencia de Sustento (manutención) de niños puede ayudar a obtener ayuda médica y financiera para el hijo de parte del padre ausente. Si usted solicita ayuda de esta agencia, los tribunales pueden establecer la paternidad y hacer cumplir el pago de obligaciones de sustento de menores. Existen otros beneficios de trabajar con la Agencia de Sustento para Menores. Por ejemplo, su hijo podrá acceder a otros beneficios financieros, como el Seguro Social, los beneficios de pensión, los beneficios para veteranos y posibles herencias. De la misma forma, su hijo se puede beneficiar del vínculo entre él y su padre. Por último, su hijo se puede beneficiar recibiendo información importante de sus antecedentes médicos. Si desea que la Agencia Sustento para Menores le ayude a establecer la paternidad o a obtener una orden judicial de ayuda con los gastos médicos, marque la opción “Sí”. Si marca esta casilla, alguien se comunicará con usted.
Sí, deseo recibir ayuda de la Agencia de Sustento de Menores. 3 3 3 3 3 3 3
Doy fe de que, a mi entender, todas las declaraciones registradas en este documento son reales y correctas. Leí o me leyeron todos los anexos de esta solicitud y comprendo mis derechos y deberes como solicitante/beneficiario. Autorizo la divulgación de cualquier información necesaria para establecer el cumplimiento de los requisitos por parte de mi familia. Comprendo que esta información puede incluir información médica sobre las personas que solicitan un seguro de salud y/o información no médica sobre dichas personas y otros. Esto puede incluir información de parte de médicos, hospitales, empleadores y compañías de seguros. He recibido o entiendo que recibiré una copia de este “Aviso de prácticas de privacidad de Medicaid”. Autorizo la copia de este formulario de divulgación para verificar información. Éste tendrá validez hasta que yo lo revoque por escrito. Entiendo que si Medicaid paga la atención en un establecimiento de enfermería, servicios de salud en domicilio o servicios brindados en virtud del Programa de alternativas comunitarias (CAP), Medicaid puede hacerse acreedor de mi testamentaría/patriminio y éste puede ser usado para hacer pagos a Medicaid. Aviso de Recuperación de Testamentaría/Propiedad: Yo entiendo que las leyes Federales y Estatales requieren que la División de Asistencia Médica (DMA, por sus siglas en inglés) pongan una demanda contra la propiedad de ciertos individuos para recuperar la cantidad que pagó el programa de Medicaid durante el periodo de tiempo que el individuo recibió asistencia para ciertos servicios médicos. Pregúntele a su trabajador de caso de Medicaid por información específica sobre cuáles servicios pueden ser aplicable en el proceso de recuperación de propiedad.
Firma del padre, madre o de otro adulto: 9__________________________________________________
DMA-5063 (04-2007)
Fecha: ________________________
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Página 5
Preferencia de idioma y necesidades especiales (Opcional) Aunque no responda a las preguntas de esta página, aún puede solicitar la Inscripción a Health Check / Health Choice.
¿Qué idioma prefiere hablar la familia? El gobierno federal exige que el estado le brinde información sobre los idiomas que habla la familia. Por favor, ayúdenos a brindar esta información sobre el padre o la madre, u otro adulto que viva en el hogar. Nombre de la persona (primer nombre, inicial del segundo, apellido)
Idioma que la persona prefiere hablar (encierre en un círculo uno)
1.
Inglés Español Otro (especifique ______________________________)
2.
Inglés Español Otro (especifique ______________________________)
3.
Inglés Español Otro (especifique ______________________________)
4.
Inglés Español Otro (especifique ______________________________)
5.
Inglés Español Otro (especifique ______________________________)
6.
Inglés Español Otro (especifique ______________________________)
¿Tiene su hijo necesidades especiales de atención de salud? Por favor, ayúdenos a mejorar los servicios para los niños con necesidades especiales de atención de salud, y a cumplir los requisitos federales de informes, respondiendo a las siguientes preguntas: Sus respuestas no afectarán la capacidad de su hijo de acceder a los servicios de Health Check o NC Health Choice. 1. ¿Alguno de sus hijos necesitan actualmente medicamentos--que no sean vitaminas--que deban ser recetados por un médico?
Sí
No Si su respuesta es ’sí’, ¿su hijo (o hijos) necesita(n) este medicamento debido a cualquier afección médica o de conducta u otra afección de salud que haya durado o que se espera que dure, por lo menos, 12 meses?
Sí
No Si su respuesta es ’sí’, indique el nombre del niño (o niños):________________________________________________ 2. ¿Alguno de sus hijos necesita más servicios de atención médica, de salud mental o de educación que lo normal o de rutina que necesita la mayoría de los niños de la misma edad?
Sí
No Si su respuesta es ’sí’, ¿su hijo (o hijos) necesita(n) estos servicios debido a cualquier afección de salud, médica o de conducta que haya durado o que se espera que dure, por lo menos, 12 meses?
Sí
No Si su respuesta es ’sí’, indique el nombre del niño (o niños):________________________________________________ ______________________________________________________________________________________________________________ 3. ¿Alguno de sus hijos está limitado o impedido de alguna manera en cuanto a su capacidad de hacer las cosas que la mayoría de los niños de su edad puede hacer?
Sí
No Si su respuesta es ’sí’, ¿esta limitación se debe a alguna afección de salud, médica o de conducta que haya durado o que se espera que dure por lo menos 12 meses?
Sí
No Si su respuesta es ’sí’, indique el nombre del niño (o niños):________________________________________________ ____________________________________________________________________ 4.
¿Alguno de sus hijos necesita terapia especial, tal como fisioterapia, terapia ocupacional o terapia del habla?
Sí
No Si su respuesta es ’sí’, ¿su hijo (o hijos) necesita(n) esta terapia debido a cualquier afección médica o de conducta u otra afección de salud que haya durado o que se espera que dure, por lo menos, 12 meses?
Sí
No Si su respuesta es ’sí’, indique el nombre del niño (o niños):________________________________________________
5.
¿Alguno de sus hijos actualmente tiene algún tipo de dificultad emocional, de desarrollo o de conducta para la cual necesita tratamiento u orientación psicológica?
Sí
No Si su respuesta es ’sí’, ¿su hijo (o hijos) necesita(n) este tratamiento u orientación debido a alguna afección médica o de conducta u otra afección de salud que haya durado o que se espera que dure, por lo menos, 12 meses?
Sí
No Si su respuesta es ’sí’, indique el nombre del niño (o niños):________________________________________________
¿FIRMÓ LA PÁGINA 5 DE LA SOLICITUD?
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Página 6
HEALTH CHECK / NC HEALTH CHOICE FOR CHILDREN APPLICATION
Better health for you and your children, peace of mind for you. Free or Low-Cost Health Insurance (Pregnant women, parents, or other adults may also use this application to apply for Medicaid as a caretaker or for Family Planning Services.) Si usted desea obtener la forma DMA-5063, solicitud en español para seguro medico para niños, comuníquese con el departamento de servicios sociales de su localidad. También puede llamar a la línea de Recursos de Salud Familiar al 1-800-367-2229. Se le atenderá en español. (You can get a Spanish application at your local department of social services or call 1-800-367-2229.)
WHAT ARE HEALTH CHECK AND NC HEALTH CHOICE FOR CHILDREN? Health Check (the Medicaid Insurance Program) and Health Choice are two similar health insurance programs. Your family’s income, the number of people in your family and the age of the children determine if you or your children qualify. This information will also be used to determine in which program you or the children will be enrolled.
WHAT ARE THE BENEFITS? •Sick visits •Checkups •Hospital care
•Counseling •Prescriptions •Dental care
•Eye exams and glasses •Hearing exams and hearing aids •And more!
Transportation - If you or your children are enrolled in Health Check, transportation to medical appointments may be provided through your department of social services. If the children are enrolled in Health Choice, you must provide your own transportation. Children with Special Health Care Needs may be eligible for additional services.
HOW DO I APPLY? It's easy. Just mail or drop off the completed application at the department of social services in the county where you live. If you would like help filling out the application, call or visit your department of social services. You can find the address and phone number in your phone book under “County Government” or by calling the North Carolina Family Health Resource Line at 1-800-367-2229. Be careful to answer all the questions completely so we can process your application more quickly. If you need more space, please attach additional pages. It can take 45 days or less to process your application. If we need additional information, we will contact you by mail. The sooner we get the information, the sooner we can let you know if your children qualify. DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 1
WHAT ELSE DO I NEED TO KNOW ABOUT HEALTH CHECK AND HEALTH CHOICE? Will My Children Get Insurance Cards?
Will I Have to Pay Enrollment Fees and a Co-pay?
YES! Your children will receive insurance cards in the mail. Please keep the card handy so you can show it at medical appointments and when you fill prescriptions.
How Do I Choose a Doctor?
Depending on your income, you may have to pay an enrollment fee of $50 to $100 per family per year. In some cases, you also may have a small co-pay for doctor visits and prescriptions. If the fee and/or co-pay apply to you, you will be notified.
The department of social services will help you choose your doctor.
Will My Children Be Enrolled Immediately?
Will I Need to Re-enroll ? YES! You will need to re-enroll to continue benefits. For most children this is done once a year. You will be contacted when it is time to re-enroll.
Health Check (the Medicaid Insurance Program) has no funding limits, so there is no waiting list. If your children are eligible for Health Choice, they may have to go on a waiting list before being enrolled if federal or state funds are not sufficient to serve more children.
WHAT ARE MY RESPONSIBILITIES? 3
You agree to tell the department of social services within 10 days if there are any changes in the information you provided on your application.
3
A state or federal reviewer may check the information on this form. You agree to participate in the review and will cooperate with the reviewer.
3
If you knowingly provide false information or if you withhold information and you or your children get health insurance for which they are not eligible, you can be lawfully punished for fraud and may be asked to repay the programs for any medical bills and/or premiums that were paid incorrectly.
3
You agree to tell the department of social services if anyone with Health Check (the Medicaid Insurance Program) is in an accident.
If Health Check (the Medicaid Insurance Program)/Health Choice pays for health care for you or your children, you give permission to the state of North Carolina to collect payments from anyone who is supposed to pay for that care. You also agree to share medical information about your children with any insurance company to get the medical bills paid.
3
For a person to be enrolled in Health Check (the Medicaid Insurance Program)/Health Choice, you must provide his/her social security number or apply for a number. Please know that these numbers will be matched by computer with other government agency records (but not the Bureau of Citizenship and Immigration Services) to verify information. If you decide not to give the numbers, the person cannot be enrolled.
3
For Health Check, provide proof of identity and U.S. citizenship or information for the county DSS to obtain the proof for those applying for benefits. For refugees and legally qualified immigrants, provide proof of legal status for those applying.
WHO CAN ANSWER MY QUESTIONS?
WHAT ARE MY RIGHTS? 3
3
Health Check (the Medicaid Insurance Program)/Health Choice cannot Contact the department of social services in the county discriminate on the basis of race, color, nationality, sex, religion, age, where you live or call the NC Family Health Resource disability in employment or the provision of services.
Line at 1-800-367-2229.
3
By law, all information that you provide remains private.
3
You can ask for a hearing if you think any decisions are unfair, incorrect or are made too late.
Before you return the application, please make sure to do the following: Read pages 1 and 2. Tear them off and keep for your records. Complete the questions on pages 3 through 6. Sign the application on page 5. DMA-5063 (04-2007)
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Page 2
For Office Use Only County DSS: _____________________ Date Received: ____________________ Case #: __________________________
Mail in
DSS
Health Dept
APPLICATION Please complete. Then send pages 3-6 to your local department of social services. If this application is being completed by or for a pregnant woman who has no other children living with her or you are applying for Family Planning, complete this application as if the pregnant woman or you is already a parent.
Tell Us About the Family 1. Who are all the children under age 21 who live in the home? Fill out this information even for children who will not be applying for Health Check/Health Choice. Social Security number, proof of identity, and citizenship status are required only for those applying for Health Check. Applying for this child (Y, N)
Name of child (first, middle initial, last)
*Asian= A
American Indian or Alaska Native= I
** Hispanic Puerto Rican= P
Hispanic Mexican= M
*Race (Use codes below. List all that apply.)
**Hispanic/Latino (Y, N) If yes, specify using codes below.
Caucasian or White= W
Is Child a U.S. citizen? (Y, N)
Social Security Number (SSN)
Black or African-American= B
Hispanic Other= H
(If different, please put your address on a separate sheet and return with this application.)
Address:
Mailing address (if different):
City:
State:
Home phone: (
Sex (M, F)
Native Hawaiian or other Pacific Islander= P
Hispanic Cuban= C
2. Where do you & the children live?
Date of birth (mo/day/yr)
Zip Code:
City:
)
Daytime phone: (
State:
Zip Code:
)
3. Who are the parents living with the children? If the children do not live with their parents, who are the adults living in the home who care for the children? Name of parent or adult (first, middle initial, last)
Date of birth (mo/day/yr)
Sex (M, F)
*Race (Use codes in 1. above. List all that apply.)
**Hispanic/Latino (Y, N) If yes, use codes in 1. above.
Children’s names and parent or adult relationship to the children (John – Mother, Mary - Stepmother)
a. Do you want to apply for pregnancy coverage for any of the people listed in #3 above?
Yes
No If you are applying for pregnancy assistance, you need to provide a statement from the doctor that includes the delivery date and the number of babies expected. However, send in the application form even if you do not have the statement from the doctor yet. If yes, for whom? ____________________________________Relationship:______________________SSN__________________ b. Do you want to apply for Medicaid for any of the people listed in #3 above? If you want to apply, you will be contacted for information about bank accounts, real and personal property, cash value of life insurance, stocks, bonds, etc. The total of these must be less than $3,000. Also, if you are eligible, you may be responsible for some of your medical bills.
Yes
No Applicants must provide their Social Security numbers and may have to give information to the child support office. If yes, for whom: _____________________________________Relationship:______________________SSN_________________ c. Do you want to apply for family planning services for any people ages 19 and older listed above?
Yes
No Applicants must provide their Social Security numbers. If yes, for whom: _____________________________________Relationship:______________________SSN_________________ DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 3
4. Is there a family member living away from the home for less than 12 months (Example: military service, attending school)?
Yes
No If yes, please give information below: Full name (first, middle initial, last)
Relationship
Reason for absence
Expected date of return
Tell Us About the Family’s Health Insurance and Medical Needs 5. Is there currently a parent not living in the home?
If yes, what is that parent’s name? (optional) Is that parent required by an agreement to pay for health insurance? 6. Does anyone applying have another health insurance plan? If yes, please give information below: Name of Insured (first, middle initial, last)
Owner of Policy
Insurance Company Name
Yes
No
Yes
No
Insurance Company Address
7. Does anyone applying need help paying medical bills from the past three months? If yes, please give the information below: We may be able to help pay those bills. Name of person(s) with bill (first, middle initial, last)
Yes
No
Insurance Company Phone Number
Group/Policy Number
Yes
No
Name of doctor, clinic and/or hospital where person was treated
Date of medical treatment
8. Has anyone applying been in an accident in the past 12 months?
Yes
No Did he/she receive medical care because of the accident?
Yes
No If yes, please tell us who. _______________________________________ When was the accident? ______/________/________ Tell Us About the Parent’s and Children’s Income 9. Who are the parents and children in the home who work, and what are their wages? Name of working person (first, middle initial, last)
Employer's name and phone number
Amount earned before deductions
$ $ $
Tips earned
How often paid (monthly, weekly, etc.)
$ $ $
Please provide copies of all of last month’s paycheck stubs for everybody listed. Send in the application even if you do not have your stubs. 10. Is there a parent or child in the home who is self-employed?
Yes
No For example, does anyone earn money from farming, own his or her own business, or have rental property income? If yes, please attach business records showing income and expenses for the last 6 months or the number of months in business if less than 6 months. If the income is annual, please attach business records for the last 12 months. 11. Has a parent or child in the home lost a job in the past three months? If yes, please complete the following: Name of person(s) who lost a job
DMA-5063 (04-2007)
Date job lost
Former employer’s name
Yes
No
Former employer's address & phone number
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 4
12. If the parent or child receives income from any other source please complete the blocks below. Type of income
Name of the person who receives other income
Amount received
Child Support:
$
Social Security:
$
Unemployment:
$
Other (Please explain):
$
How often received (monthly, weekly, etc.)
Tell Us About the Parent’s and Children’s Expenses Some of these expenses may be used to reduce the income that we count to determine enrollment in Health Check/Health Choice. 13. Does a working parent living in the home pay for childcare, a babysitter or care for dependent adult? If yes, please fill in the information: Name, address & phone number of sitter or childcare provider
Name of person cared for
Name of person paying for care
Yes
No
Amount paid
How often paid (monthly, weekly, etc.)
$ $ 14. Does a parent living in the home pay child support for a child who is not living in the home? If yes, please fill in the information. Who pays the support & to whom
For whom is the support paid
Is it court ordered (Y, N)
Yes
No
Amount paid
Please Attach Verification
How often paid (monthly, weekly, etc.)
$ $ Tell Us If You Would Like Help With Child Support The Child Support Agency can help get financial and medical help for the child from the child’s absent parent. If you seek assistance from the Child Support Agency, the courts can establish paternity and establish and enforce medical support obligations. There are other benefits to working with the Child Support Agency. For example, your child may be eligible for other financial benefits, including Social Security, pension benefits, veteran’s benefits and possible inheritance. Also, your child may benefit by having a bond between parent and child. Finally, your child may benefit by getting important medical history information. If you want the Child Support Agency’s help in establishing paternity or in getting a medical support order through the court, check the “Yes” box. If you check the box, someone will contact you.
Yes, I would like help from the Child Support Agency. 3 3 3 3 3 3
I attest that all statements recorded on this document are true and correct to the best of my knowledge. I have either read or had read to me all attachments to this application, and I understand my rights and responsibilities as an applicant/recipient. I authorize the release of any information necessary to establish my family's eligibility. I understand that this information may include medical information about the individuals applying for health insurance and/or nonmedical information about individuals applying and others. This might include information from doctors, hospitals, employers and insurance companies. I have received or understand that I will receive a copy of the “Medicaid Notice of Privacy Practices.” I authorize the copying of this release form to verify information. It shall remain valid and in force until revoked by me in writing. I understand that if Medicaid pays for nursing facility care, in-home health services, or services provided under the Community Alternatives Program (CAP), Medicaid may become a creditor of my estate and my estate may be subject to recovery to repay Medicaid.
Signature of parent or other adult: 9__________________________________________________ Date: ________________________ DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
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Language Preference and Special Needs (Optional) You may still apply for Health Check/Health Choice even if you don’t answer the questions on this page.
What Language Does the Family Prefer to Speak? The federal government requires the State to provide information about the languages the family speaks. Please help us by providing the information for the parent/other adult living in the home. Name of person (first, middle initial, last)
Language person prefers to speak (circle one)
1.
English
Spanish
Other (Specify______________________________)
2.
English
Spanish
Other (Specify______________________________)
3.
English
Spanish
Other (Specify______________________________)
4.
English
Spanish
Other (Specify______________________________)
5.
English
Spanish
Other (Specify______________________________)
6.
English
Spanish
Other (Specify______________________________)
Does Your Child Have Special Health Care Needs? Please help us improve services for children with special health care needs and meet federal reporting requirements by answering these questions. The answers will not affect your child’s eligibility for Health Check or NC Health Choice. 1. Do any of your children currently need medicine prescribed by a doctor other than vitamins?
Yes
No If yes, does your child (or children) need this medicine because of any medical, behavioral or other health condition that
Yes
No has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children):____________________________________________________________________ 2.
Do any of your children need more medical care, mental health or education services than usual or routine for most children of the same age?
Yes
No If yes, does your child (or children) need these services because of any medical, behavioral or health condition
Yes
No that has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children): ______________________________________________________________________________________________________________
3.
Are any of your children limited or prevented in any way in their ability to do the things most children their age can do?
Yes
No If yes, is this limitation because of any medical, behavioral or health condition that has lasted or is expected
Yes
No to last at least 12 months? If yes, please list the name of the child (or children): ____________________________________________________________________
4.
Do any of your children need special therapy, such as physical, occupational, or speech therapy?
Yes
No If yes, does your child (or children) need this therapy because of any medical, behavioral or other health condition that
Yes
No has lasted or is expected to last at least 12 months? If yes, please list the name of the child (or children):_____________________________________________________________________
5.
Do any of your children currently have any kind of emotional, developmental or behavioral difficulty for which they need treatment or counseling?
Yes
No If yes, does your child (or children) need this treatment or counseling because of any medical, behavioral or other
Yes
No health condition that has lasted or is expected to last at least 12 months? If yes, please list the name of your child (or children):____________________________________________________________________
DID YOU SIGN THE APPLICATION ON PAGE 5? DMA-5063 (04-2007)
Questions about Health Check/Health Choice? Call 1-800-367-2229.
Page 6
APPLICATION ADDENDUM MEDICAID FAMILY PLANNING WAIVER (FPW) PROGRAM
In order to evaluate for all Medicaid programs, including the Medicaid Family Planning Waiver Program, you must answer the questions below. The Medicaid Family Planning Waiver (FPW) Program provides coverage of family planning services for women ages 19-55 or men ages 19-60 if they have not had a medical procedure to prevent them from having a baby or fathering a baby. Services include, but are not limited to: an annual physical examination, birth control methods, pregnancy tests, pap tests, screening for sexually transmitted infections (STIs) and voluntary sterilizations for women and men.
QUESTIONS FOR WOMEN: Name_________________________________________________ 1.
Have you had your tubes tied, cut or burnt?
2.
Have you been sterilized by having any other medical procedure that would prevent you from having a baby? Yes No
Yes
No
QUESTIONS FOR MEN: Name_____________________________________________________________ 1.
Have you had a vasectomy?
Yes
No
2.
Have you been sterilized by having any other medical procedure that would Yes No prevent you from fathering a baby?
If you are not eligible for full Medicaid, but are eligible for the Medicaid Family Planning Waiver (FPW) Program, the FPW Medicaid is authorized for 12 months. If you later want full Medicaid during this 12 month period, you can not apply for retro Medicaid. Eligibility will be determined based on this 12 month certification period.
After reading the information above, do you wish to be evaluated for the Medicaid Family Planning Waiver (FPW) Program? Yes No
DMA-5063A 11/01/08 DMA-3265 Figure 1
1 DIRECTORY OF NORTH CAROLINA COUNTY DEPARTMENTS OF SOCIAL SERVICES Last Updated: October 13, 2009
01.
Alamance County DSS Ms. Susan Osborne, Director 336-229-2910 319 North Graham Hopedale Road, Suite C Burlington, NC 27217 Tel. #336-570-6532 Fax # Admin. 336-570-6538 Courier Number: 17-42-05
02.
Alexander County DSS Ms. Karen Hoyle, Director 604 7th Street, SW Taylorsville, NC 28681 Tel. #828-632-1080, Ext. 357 Fax #828-632-1092 Courier Number: 15-83-09
03.
Alleghany County DSS Mr. John Blevins, Director Post Office Box 247 182 Doctor Street Sparta, NC 28675 Tel. #336-372-2411 Fax #336-372-2635 Courier Number: 15-97-06
04.
Anson County DSS Ms. Lula Jackson, Director 118 North Washington Street Wadesboro, NC 28170 Tel. #704-694-9351 Fax #704-694-1608 Courier Number: 03-82-19
05.
Ashe County DSS Mrs. Donna Weaver, Director (336) 546-5719 150 Government Circle, Suite 1400 Jefferson, NC 28640 Tel. #336-846-5700 Fax #336-846-5779 Courier Number: 15-66-04
06.
Avery County DSS Mr. Tom Hughes, Director Post Office Box 309 175 Linville Street Newland, NC 28657 Tel. #828-733-8248 Fax #828-733-8245 Courier Number: 12-40-11
07.
Beaufort County DSS Ms. Sonya Toman, Director (252) 940-6036 Post Office Box 1358 632 West 5th Street Washington, NC 27889 Tel. #252-975-5500 Fax #252-975-5555 Courier Number: 16-08-01
08.
Bertie County DSS Mr. Morris Rascoe, Director Post Office Box 627 1006 Wayland Street Windsor, NC 27983 Tel. #252-794-5320 Fax #252-794-5344 Courier Number: 10-93-18
09.
Bladen County DSS Ms. June Koenig, Director 910-862-6858 Post Office Box 369 208 McKay Street Elizabethtown, NC 28337 Tel. #910-862-6800 Fax #910-862-6801 Courier Number: 04-26-17
10.
Brunswick County DSS Mr. Jamie Orrock, Director Post Office Box 219 60 Government Road Bolivia, NC 28422-0219 Tel. #910-253-2077 Director’s #910-253-2080 Fax #910-253-2071 Courier Number: 04-20-19
2 11.
Buncombe County DSS Ms. Amanda Stone, Director 828-250-5588 Post Office Box 7408 40 Coxe Avenue Asheville, NC 28802 Tel. #828-250-5500 Fax #828-250-5945 Courier Number: 12-50-02
12.
Burke County DSS Mr. David G. Smith, Director 828-439-2003 Post Office Box Drawer 549 700 East Parker Road Morganton, NC 28680-0549 Tel. #828-439-2000 Fax #828-439-2137 Courier Number: 15-01-06
13.
Cabarrus County DSS Mr. William “Ben” Rose, Director (704) 920-1552 1303 South Cannon Boulevard Kannapolis, NC 28083 Tel. #(704) 920-1400 Fax #704-920-1401 Courier Number: 05-09-02
14.
Caldwell County DSS Joyce Edwards, Director 1966-H Morganton Boulevard, SW Lenoir, NC 28645 Tel. #828-426-8200 Fax #828-426-8398 Courier Number: 15-24-17
15.
Camden County DSS Ms. Sylvia Holley, Director Post Office Box 70 117 North Highway 343 Camden, NC 27921 Tel. #252-331-4787 Fax #252-355-1009 Courier Number: 10-41-10
16.
Carteret County DSS David Atkinson, Director Post Office Box 779 210 Craven Street Beaufort, NC 28516 Tel. #252-728-3181 Fax #252-728-3631 Courier Number: 11-14-24
17.
Caswell County DSS Ms. Dianne Moorefield, Director 336-694-2037 Post Office Box 1538 175 East Church Street Yanceyville, NC 27379 Tel. #336-694-4141 Fax #336-694-1816 Courier Number: 02-51-14
18.
Catawba County DSS Mr. John Eller, Director 828-695-5603 Post Office Box 669 Newton, NC 28658 3030 11th Avenue Drive, SE Hickory, NC 28602 Tel. #828-695-5600 Fax #828-695-2497 Courier Number: 09-70-03
19.
Chatham County DSS Ms. Sandra Coletta, Director (919) 642-6917 Post Office Box 489 102 Camp Drive Pittsboro, NC 27312 Tel. #919-542-2759 Fax #919-542-6355 Courier Number: 13-25-02
20.
Cherokee County DSS Ms. Lisa P. Davis, Director 40 Peachtree Street Murphy, NC 28906 Tel. #828-837-7455 Fax #828-837-9789 Courier Number: 08-52-03
3 21.
Chowan County DSS Mr. William B. Rose, Director Post Office Box 296 113 East King Street Edenton, NC 27932 Tel. # 252-482-7441 Fax # 252-482-7041 Courier Number: 10-62-13
22.
Clay County DSS Mrs. Deborah G. Mauney, Director Post Office Box 147 55 Riverside Circle Hayesville, NC 28904 Tel. #828-389-6301 Fax #828-389-6427 Courier Number: 08-51-07
23.
Cleveland County DSS Ms. Karen D. Ellis, Director 704-487-0661, Ext. 206 Drawer 9006 130 South Post Road Shelby, NC 28150-9006 Tel. #704-487-0661 Fax #704-484-1051 Courier Number: 06-45-10
24.
Columbus County DSS Ms. Joan Stephens, Interim Director 40 Government Complex Road Whiteville, NC 28472-0397 Tel. #910-642-2800 Fax #910-641-3970 Courier Number: 04-21-23
25.
Craven County DSS Mr. Kent Flowers, Jr., Director 2818 Neuse Boulevard Post Office Box 12039 New Bern, NC 28561-2039 Tel. #252-636-4900 Fax #252-636-4946 Courier Number: 16-66-02
26.
Cumberland County DSS Ms. Brenda Jackson, Director (910) 677-2035 1225 Ramsey Street Post Office Box 2429 Fayetteville, NC 283021 Tel. #910-323-1540 Fax # 910-677-2801 Courier Number: 14-62-41
27.
Currituck County DSS Ms. Kathlyn Romm, Director 2793 Caratoke Highway Post Office Box 99 Currituck, NC 27929 Tel. #252-232-3083 Fax #252-232-2167 Courier Number: 10-68-01
28.
Dare County DSS Mr. Jay F. Burrus, Director Post Office Box 669 Manteo, NC 27954 Tel. #252-475-5500 Fax # 252-473-9824 Courier Number: 16-30-05
29.
Davidson County DSS Mr. Keith Johnson, Director 336-242-2562 Post Office Box 788 Lexington, NC 27293 913 Greensboro Street Tel. # Lex. 366-242-2500 Fax # Lex. 366-249-7588 Courier Number: 13-50-26
30.
Davie County DSS Ms. Becky Finney, Director 228 Hospital St Post Office Box 517 Mocksville, NC 27028 Tel. # 336-751-8800 Fax # 336-751-1639 Courier Number: 09-40-12
4 31.
Duplin County DSS Mrs. Millie I. Brown, Director 423 North Main Street Post Office Box 969 Kenansville, NC 28349 Tel. #910-296-2200 Fax #910-296-2323 Courier Number: 11-20-16
32.
Durham County DSS Ms. Gerri Robinson, Director 220 East Main Street Post Office Box 810 Durham, NC 27702-0810 Tel. #919-560-8000 Fax #919-560-8102 Courier Number: 17-24-13
33.
Edgecombe County DSS Ms. Marva Scott, Director (252) 641-7882 3003 North Main Street Tarboro, NC 27886 Tel. #252-641-7611 Fax #252-641-7980 Rocky Mount Office 301 South. Fairview Road Rocky Mount, NC 27801 Tel. #252-985-4101 Fax #252-985-1615 Courier Number: 07-50-03& 07-65-01(RM)
34.
Forsyth County DSS Mr. Joe Raymond, Director 741 North Highland Avenue Winston-Salem, NC 27101 Tel. #336-703-3400 Fax #336-727-2850 Courier Number: 13-07-01
35.
Franklin County DSS Ms. Nicki Griffin, Director (919) 496-8118 107 Industrial Drive Post Office Box 669 Louisburg, NC 27549 Tel. #919 496-5721 Fax #919 496-8137 Courier Number: 07-06-04
36.
Gaston County DSS Mr. Keith Moon, Director (704) 862-7888 330 North Marietta Street Gastonia, NC 28052 Tel. #704-862-7500 Fax #704-862-7885 Courier Number: 06-54-17
37.
Gates County DSS Ms. Colleen Turner, Director Post Office Box 185 200 Court Street Gatesville, NC 27938 Tel. #252-357-0075 Fax #252-357-2132 Courier Number: 10-21-08
38.
Graham County DSS Ms. Kristy Smith, Director 196 Knight Street Post Office Box 1150 Robbinsville, NC 28771 Tel. #828-479-7911 Fax #828-479-7928 Courier Number: 08-40-02
39.
Granville County DSS Mr. Louis W. Bechtel, Director Post Office Box 966 102 Lanier Street Oxford, NC 27565 Tel. #919-693-1511 Fax #919-603-5090 Courier Number: 17-05-01
40.
Greene County DSS Ms. Christy Nash, Director 227 Kingold Boulevard, Suite A Snow Hill, NC 28580 Tel. #252-747-5932 Fax #252-747-8654 Courier Number: 01-81-06
5 41.
Guilford County DSS Mr. Robert Williams, Director (336) 641-3053 Post Office Box 3388 1203 Maple Street (27405) Greensboro, NC 27402-3388 Tel. #336-641-3000 Fax # 336-641-5647 Courier Number: 02-15-38
42.
Halifax County DSS Mr. Michael G. Felt, Director (252) 536-6444 4421 Hwy 301 Post Office Box 767 Halifax, NC 27839 Tel. #252-536-2511 Fax #252-536-6539 Courier Number: 07-42-01
43.
Harnett County DSS Mr. Robert P.(Pat) Cameron, Director (910) 893-7583 311 Cornelius Harnett Boulevard Lillington, NC 27546 Tel. #910-893-7500 Fax #910-893-6604 Courier Number: 14-73-02
44.
Haywood County DSS Mr. Ira Dove, Director 486 East Marshall Street Waynesville, NC 28786 Tel. #828-452-6620 Fax #828-452-6686 Courier Number: 08-14-12
45.
Henderson County DSS Mr. Liston B. Smith, Director (828) 694-6308 1200 Spartanburg Highway, Suite 300 Hendersonville, NC 28792 Tel. #828-697-5500 Fax #828-697-4544 Courier Number: 06-92-03
46.
Hertford County DSS Ms. Gwen Burns, Director 704 King Street Post Office Box 218 Winton, NC 27986 Tel. #252-358-7830 Fax # Winton Office 252-358-0597 Ahoskie Office 252-332-4710 Courier Number: 10-13-09
47.
Hoke County DSS Ms. Della Sweat, Director (910) 878-1920 314 S. Magnolia Street Post Office Box 340 Raeford, NC 28376 Tel. #910-875-8725 Fax #910-875-1068 Courier Number: 14-80-12
48.
Hyde County DSS Ms. Gloria C. Spencer, Director (252) 926-4199 1430 Main Street Post Office Box 220 Swan Quarter, NC 27885 Tel. #252-926-4199 Fax #252-926-3711 Courier Number: 16-40-05
49.
Iredell County DSS Mr. Donald C. Wall, Director (704) 878-5000 Post Office Box 1146 549 Eastside Drive Statesville, NC 28625 Tel. #704-873-5631 Fax #704-878-5419 Courier Number: 09-34-01
50.
Jackson County DSS Mr. Robert B. Cochran, Director (828) 587-2038 15 Griffin Street Sylva, NC 28779 Tel. #828-586-5546 Fax #828-586-6270 Courier Number: 08-23-17
6 51.
Johnston County DSS Mr. G. Earl Marett, Director (919) 989-5301 Post Office Box 911 714 North Street Smithfield, NC 27577 Tel. #919 989-5300 Fax #919-989-5324 Courier Number: 01-64-33
52.
Jones County DSS Ms. Thelma A. Simmons, Director 118 Highway 58 North Post Office Box 250 Trenton, NC 28585 Tel. #252-448-2581 Fax #252-488-5651 Courier Number: 11-18-10
53.
Lee County DSS Ms. Brenda Potts, Director 530 Carthage Street Post Office Box 1066 Sanford, NC 27330 Tel. #919-718-4690 Fax #919-718-4634 Courier Number: 14-42-05
54.
Lenoir County DSS Mr. Jack B. Jones, Director (252) 559-6361 130 West King Street Post Office Box 6 Kinston, NC 28502-0006 Tel. #252-559-6400 Fax #252-559-6381 Courier Number: 01-22-20
55.
Lincoln County DSS Ms. Susan L. McCracken, Director (704) 736-8576 1136 East Main Street Post Office Box 130 Lincolnton, NC 28093-0130 Tel. #704-732-0738 Fax #704-736-8692 Courier Number: 09-02-07
56.
Macon County DSS Mrs. Jane Kimsey, Director (828) 349-2130 Lakeside Government Complex 1832 Lakeside Drive Franklin, NC 28734 Tel. #828-349-2124 Fax #828-349-2401 Courier Number: 08-49-03
57.
Madison County DSS Ms. Flossie Ball, Director Post Office Box 219 5707 U.S. Highway 25/70, Unit D Marshall, NC 28753 Tel. #828-649-2711 Fax #828 649-2097 Courier Number: 12-20-07
58.
Martin County DSS Ms. Susan Davenport, Director (252) 789-4402 305 East Main Street Post Office Box 809 Williamston, NC 27892 Tel. #252-789-4400 Fax #252-789-4409 Courier Number: 10-84-30
59.
McDowell County DSS Mr. Phillip Hardin, Director 145 East Court Street Post Office Box 338 Marion, NC 28752 Tel. #828-652-3355, Ext. 117 Fax #828-652-9167 Courier Number: 12-93-20
60.
Mecklenburg County DSS Ms. Mary E. Wilson, Director (704) 336-6279 Fax (704) 336-5887 301 Billingsley Road Post Office Box 220999 Charlotte, NC 28222 Tel. #704-336-3150 Fax #704-336-3361 Courier Number: 05-14-12
7 61.
Mitchell County DSS Mr. Larry L. Deyton, Director 347 Long View Drive Bakersville, NC 28705-0365 102 East Spring Street Tel. #828-688-2175 Fax #828-688-4940 Courier Number: 12-72-07
62.
Montgomery County DSS Mr. James Sanders, Director 102 E. Spring Street Post Office Drawer N Troy, NC 27371 Tel. #910-576-6531 Fax #910-576-5016 Courier Number: 03-96-15
63.
Moore County DSS Mr. John L. Benton, Director 1036 Carriage Oaks Drive Post Office Box 938 Carthage, NC 28327 Tel. #910-947-2436 Fax #910-947-1618 Courier Number: 03-41-08
64.
Nash County DSS Ms. Laura O’Neal, Director (252) 459-9876 120 West Washington Street Post Office Drawer 819 Nashville, NC 27856 Tel. #252-459-9818 Fax #252-459-9833 Courier Number: 07-72-11
65.
New Hanover County DSS LaVaughn Nesmith, Director (910) 798-3631 1650 Greenfield Street Post Office Drawer 1559 Wilmington, NC 28402 Tel. #910-798-3400 Fax #910-798-3627 Courier Number: 04-10-16
66.
Northampton County DSS Dr. Albert Wentzy, Director 9467 NC 305 Highway Post Office Box 157 Jackson, NC 27845 Tel. #252-534-5811 Fax #252-534-0061 Courier Number: 10-03-12
67.
Onslow County DSS Mr. Roger Penrod, Director 1915 Onslow Drive Extension Post Office Box 1379 Jacksonville, NC 28541 Tel. #910-455-4145 Fax #910-455-2901 Courier Number: 11-08-20
68.
Orange County DSS Ms. Nancy Coston, Director (919) 245-2802 300 West Tryon Street Hillsborough, NC 27278 Tel. #919-245-2800 Fax #919-644-3005 Courier Number: 17-50-11
69.
Pamlico County Human Services Center Mr. Robert S. Johnson, Director 828 Alliance Main St. Bayboro, NC 28515 Tel. #252-745-4086 Fax #252-745-73-84 Courier Number: 16-50-11
70.
Pasquotank County DSS Melissa Stokely, Director 709 Roanoke Avenue Elizabeth City, NC 27909 Tel. #252-338-2126 Fax #252-338-7512 Courier Number: 10-32-01
71.
Pender County DSS Dr. Reta M. Shiver, Director (910) 259-1376 810 South Walker Street Post Office Drawer 1207 Burgaw, NC 28425 Tel. #910-259-1240 Fax #910-259-1418 Courier Number: 04-69-11
72.
Perquimans County DSS Ms. Susan M. Chaney, Director Post Office Box 107 103 Charles Street Hertford, NC 27944 Tel. #252-426-7373 Fax #252-426-1240 Courier Number: 10-53-09
8 73.
Person County DSS Ms. Beverly W. Warren, Director (336) 503-1131 Post Office Box 770 355B S. Madison Blvd Roxboro, NC 27573 Tel. #336-599-8361 Fax #336-597-9339 Courier Number: 02-33-17
74.
Pitt County DSS Mr. George Perry, Director (252) 902-1064 1717 West Fifth Street Greenville, NC 27834 Tel. #252-902-1110 Fax #252-413-1299 Courier Number: 01-48-44
75.
Polk County DSS Ms. Sue Rhodes, Director 330 Carolina Drive Tryon, NC 28782 Tel. #828-859-5825 Fax #828-859-9703 Courier Number: 06-74-02
76.
Randolph County DSS Ms. Beth Duncan, Director 1512 North Fayetteville Street P.O. Box 3239 Asheboro, NC 27204-3239 Tel. #336-683-8000 Fax #336-683-8131 Courier Number: 13-67-01
77.
Richmond County DSS Mrs. Tammy Schrenker, Director (910) 997-8444 125 Caroline Street Post Office Box 518 Rockingham, NC 28380 Tel. #910-997-8400 Fax #910-997-8447 Courier Number: 03-75-01
78.
Robeson County DSS Ms .Becky Morrow, Director (910) 671-3711 435 Caton Road Lumberton, NC 28360 Tel. #910-671-3500 Fax #910-671-3092 Courier Number: 14-92-04
79.
Rockingham County DSS Mr. Larry Johnson, Director Post Office Box 361 Wentworth, NC 27375 Tel. #336-342-1394 Fax #336-634-1847 Courier Number: 02-28-07
80.
Rowan County DSS Ms. Sandra Wilkes, Director (704) 216-8422 1236 West Innes Street Salisbury, NC 28144 Tel. #704-216-8330 Fax #704-638-3041 Courier Number: 05-30-05
81.
Rutherford County DSS Mr. John Carroll, Director (828) 287-6165 389 Fairground Road Post Office Box 237 Spindale, NC 28160 Tel. #828-287-6199 Fax #828-287-6350 Courier Number: 06-64-12
82.
Sampson County DSS Ms. Sarah Bradshaw, Director 405 County Complex Road Post Office Box 1105 Clinton, NC 28328 Tel. #910-592-7131 Fax #910-592-4297 Courier Number: 11-33-29
9 83.
Scotland County DSS Mr. Joe Knott (910) 277-2525 x 3385 1405 West Boulevard Post Office Box 1647 Laurinburg, NC 28353 Tel. #910-277-2500 Fax #910-277-2402 Courier Number: 14-38-03
84.
Stanly County DSS Sharon Scott, Director (704) 986-2005 1000 North First Street, Suite 2 Albemarle, NC 28001 Tel. #704-982-6100 Fax #704-983-5818 Courier Number: 03-23-02
85.
Stokes County DSS Janice Spencer, Director 1010 Highway 8 & 89 North Post Office Box 30 Danbury, NC 27016 Tel. #336-593-2861 Fax #336-593-9362 Courier Number: 09-16-01
86.
Surry County DSS Wayne Black, Director 118 Hamby Road Dobson, NC 27017 Tel. #336-401-8700 Fax #336-401-8750 Courier Number: 09-92-02
87.
Swain County DSS Tammy Cagle, Director 80 Academy St. Post Office Box 610 Bryson City, NC 28713 Tel. #828-488-6921 Fax #828-488-8271 Courier Number: 08-30-10
88.
Transylvania County DSS Mr. Talmadge “Stoney” Blevins, Director 106 E. Morgan St. Brevard, NC 28712 Tel. #828-884-3174 Fax #828-884-3263 Courier Number: 06-02-12
89.
Tyrell County DSS Sandra Walker, Director 102 N. Road Street Post Office Box 599 Columbia, NC 27925 Tel. #252-796-3421 Fax # 252-796-1732 Courier Number: 16-20-02
90.
Union County DSS D. Dontar Latson, Director (704) 296-4301 1212 West Roosevelt Boulevard Post Office Box 489 Monroe, NC 28111-0489 Tel. #704-296-4300 Fax #704-296-6151 Courier Number: 03-07-01
91.
Vance County DSS Kaye Fields, Director (252) 738-3770 350 Ruin Creek Road Henderson, NC 27536 Tel. #252-492-5001 Fax #252-438-5997 Courier Number: 07-24-18
92.
Wake County DSS Ramon Rojano, Director (919) 212-7302 Fax (919) 212-7309 220 Swinburne Road Post Office Box 46833 Raleigh, NC 27620 Tel. #919-212-7000 Fax #919-212-7285 Courier Number: 51-91-00
10 93.
Warren County DSS Mr. Jeff Woodard, Director 307 North Main Street Warrenton, NC 27589 Tel. #252-257-5000 Fax #252-257-4656 Courier Number: 07-30-19
94.
Washington County DSS Mr. Jerry W. Rhodes, Director 209 East Main Street Post Office Box 10 Plymouth, NC 27962 Tel. #252-793-4041 Fax #252-793-3195 Courier Number: 16-13-01
95.
Watauga County DSS Mr. James Atkinson, Director 132 Poplar Grove Road Connector, Suite C Boone, NC 28607 Tel. #828-265-8100 Fax #828-265-7638 Courier Number: 15-92-11
96.
Wayne County DSS Ms. Debbie Jones, Director (919) 731-4119 301 North Herman Street Goldsboro, NC 27530 Tel. #919-580-4034 Fax #919-731-1293 Courier Number: 01-15-33
97.
Wilkes County DSS Mr. James D. Bumgarner, Director (336) 651-7407 304 College Street Post Office Box 119 Wilkesboro, NC 28697 Tel. #336-651-7400 or 336-651-7490 Fax #336-651-7568 Courier Number: 15-10-09
98.
Wilson County DSS Mr. J. Glenn Osborne, Director 100 N.E Gold Street Post Office Box 459 Wilson, NC 27894-0459 Tel. #252-206-4000 Fax #252-237-1544 Courier Number: 01-54-01
99.
Yadkin County DSS Mr. Edsel (Eddie) Wooten, Director Post Office Box 548 250 Willow Street Yadkinville, NC 27055 Tel. #336-679-4210 Fax #336-679-2664 Courier Number: 09-12-22
100. Yancey County DSS Ms. Alice Elkins, Director 111 Oak Crest Road Post Office Box 67 Burnsville, NC 28714 Tel. #828-682-6148 Fax #828-682-6712 Courier Number: 12-45-03
CENTERS FOR MEDICARE & MEDICAID SERVICES
Medicare
&You
2010
This is the official government handbook with important information about the following: What's new Medicare costs What Medicare covers Health and prescription drug plans Your Medicare rights Health information technology
Want to Save? Extra Help is available! More than 2 million people qualify to get Extra Help paying their Medicare prescription drug costs, but don’t know it. Don’t miss out on a chance to save. See pages 78–81 to learn more. Choose to get future handbooks electronically. Save tax dollars and help the environment by signing up to access your future “Medicare & You” handbooks electronically (also called the eHandbook). Visit www.MyMedicare.gov to request future eHandbooks, including the 2011 version. We’ll email you next October when the new eHandbook is available. The email will include a link to the handbook on www.medicare.gov. You won’t get a copy of your handbook in the mail if you choose to get it electronically. Did your household get more than one copy of “Medicare & You?” This may happen if there is a slight difference in how your or your spouse’s address is entered in Social Security’s mailing system. If you would like to get only one copy in the future, call 1‑800‑MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Welcome to Medicare & You 2010 I am honored and excited to introduce this handbook—your best and official source of answers to your Medicare questions. At the U.S. Department of Health and Human Services, we are doing more than ever to carry Medicare into the future. Every day brings new commitment to advance the goals of health reform by reducing costs, offering choices, and making sure you have access to quality, affordable health care. Your good health is our top priority. On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act. This law targets two areas, among many, to ensure the health and well-being of the Nation: 1. Strengthening preventive care and wellness to enable Americans to live longer, healthier lives. 2. Investing in health information technology to improve the quality of health care and reduce medical errors. There are some things that you can do to help these efforts: ■■Take advantage of Medicare’s preventive services. Use the checklist on page 40, and ask your doctor or other health care provider what preventive services you need. ■■Learn about the technology available to help improve your health care. Look on page 123 to learn more about health information technology. This handbook also includes other important facts and changes you will need for 2010. For the latest information about changes to Medicare, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Yours in good health, /s/ Kathleen Sebelius Secretary U.S. Department of Health and Human Services
4
How to Use This Handbook Please keep this handbook for future reference. Information was correct when it was printed. Call 1-800-MEDICARE (1‑800‑633‑4227), or visit www.medicare.gov to get the most current information. TTY users should call 1‑877‑486‑2048. Find What You Need Table of Contents
List of topic areas by section
Pages 5–6
Index
Alphabetical list of topics
Pages 7–10
Mini Tables of Contents
List of topics within each section
Pages 15, 41, 77, 85, 99, 105
Blue words in the text are explained in the “Definitions” section
Pages 115–118
Blue Words in the Text
Highlights important information Highlights preventive services
Throughout handbook Pages 26–38, 40
“Medicare & You” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.
Contents
5
Medicare & You 2010
4 7 11 12
12 13 14
How to Use This Handbook Index—A Quick Way to Find What You Need What’s New and Important in 2010 Medicare Basics
What Is Medicare? Your Medicare Coverage Choices Where to Get Your Medicare Questions Answered
15 Section 1—Medicare Part A and Part B (What’s Covered) 19 25 39 40
Part A-Covered Services Part B-Covered Services What’s NOT Covered by Part A and Part B? Preventive Services Checklist
41 Section 2—Your Medicare Choices 42 44 45 50 58 60 62 63
Decide How to Get Your Medicare Things to Consider When Choosing or Changing Your Coverage Original Medicare Medicare Advantage Plans (like an HMO or PPO) (Part C) When Can You Join, Switch, or Drop a Medicare Advantage Plan? Other Medicare Health Plans Medicare Prescription Drug Coverage (Part D) When Can You Join, Switch, or Drop a Medicare Drug Plan?
Continued _ What’s new? 11
What’s covered? 19
Coverage choices 43
6
Contents
(continued)
73 Who Pays First When You Have Other Insurance? 74 Medigap (Medicare Supplement Insurance) Policies
77 Section 3—Programs for People with Limited Income and Resources 78 Extra Help Paying for Medicare Prescription Drug Coverage (Part D) 82 Medicaid 83 Medicare Savings Programs (Help with Medicare Costs)
85 Section 4—Protecting Yourself and Medicare 86 86 92 94 96
Your Medicare Rights What Is an Appeal? How Medicare Uses Your Personal Information Protect Yourself from Fraud and Identity Theft Protect Yourself and Medicare from Billing Fraud
99 Section 5—Planning Ahead 105 Section 6—For More Information
115 119 123
Need help
78 with costs?
(Phone, Web sites, Publications)
Section 7—Definitions Medicare Costs Using Computers to Manage Your Health Information
Fraud and
94 identity theft
119 Medicare costs
Medicare & You 2010
Index
7
NOTE: The page number shown in bold provides the most detailed information. A
Abdominal Aortic Aneurysm 26, 40 Acupuncture 39 Advance Beneficiary Notice 89 Advance Directives 103–104 ALS (Amyotrophic Lateral Sclerosis) 17, 22 Ambulance Services 26, 38 Ambulatory Surgical Center 26, 28 Anxiety (see Mental Health Care) 33 Appeal 86–91, 106–107 Artificial Limbs 35 Assignment 25, 46–47
B
Balance Exam 31 Barium Enema 28, 40 Benefit Period 115, 120 Bills 46, 73, 89, 96, 107 Blood 19, 26, 120–121 Blue Words 4, 115–118 Bone Mass Measurement (Bone Density) 27, 40 Braces (arm/leg/back/neck) 35 Breast Exam 34, 40
C
Cardiac Rehabilitation 27 Cardiovascular Screenings 27, 40 Cataract 30 Catastrophic Coverage 66 Children’s Health Insurance Program 84 Chiropractic Services 27 Claims 45–47, 87, 106–107 Clinical Laboratory Services 27, 121 Clinical Research Studies 20, 27 COBRA 22, 24, 71
C (continued)
Coinsurance 19–20, 26–39, 43, 45, 52, 65–66, 74, 78, 83, 115, 120–121 Colonoscopy 26, 28, 40 Colorectal Cancer Screenings 28, 40 Community-Based Programs 101 Consolidated Omnibus Budget Reconciliation Act (COBRA) 22, 24, 71 Contract (private) 48 Coordination of Benefits 14, 73 Copayment 19–20, 26–39, 54, 65–66, 74–75, 78, 115, 120–121 Cosmetic Surgery 39 Costs 16, 21, 25–38, 44–47, 54, 65–66, 74, 78–83, 119–122 Coverage Determination (Part D) 90–91 Coverage Gap 65–66, 78 Covered Services (Part A and Part B) 19–20, 26–38, 40, 120–121 Creditable Prescription Drug Coverage 49, 62, 67, 71–72, 116 Custodial Care 20, 100, 116
D
Deductible 19–20, 25–39, 43, 45, 52, 54, 65–66, 74–75, 78, 83, 116, 120–121 Definitions 115–118 Demonstrations/Pilot Programs 13, 61, 117 Dental Care and Dentures 39, 50, 84 Department of Defense 14 Department of Health and Human Services (Office of Inspector General) 14, 96–97 Department of Veterans Affairs 14, 67, 72 Depression (see Mental Health Care) 33 Diabetes 29–31, 33, 40, 57
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Index
NOTE: The page number shown in bold provides the most detailed information. D (continued)
Dialysis (Kidney Dialysis) 12, 18, 32, 52–53, 55, 57, 107–108 Discrimination 86, 97 Disenroll 52, 59, 118 Drug Plan 43–44, 49, 62–72, 78–81, 90–91, 122 Drugs (outpatient) 35, 69, 120 Drugs (prescription) 12, 35, 44–49, 55–57, 62–72, 78–82, 90–91, 120 Durable Medical Equipment (like walkers) 19, 30, 32, 35, 47, 120–121
E
EKGs 30, 36, 40 Eldercare Locator 101–102 Electronic Handbook inside front cover Electronic Health Record 44, 123 Electronic Prescribing 123 Emergency Department Services 20, 30, 69, 106 Employer Group Health Plan Coverage 24, 43–45, 49, 52–53, 60, 63, 67, 71, 73, 80, 100 End-Stage Renal Disease (ESRD) 12, 18, 22–23, 32, 51–53, 73 Enroll 17–18, 21–24, 58–59, 63–64, 75, 79–80 Equipment (like walkers) 19, 30, 32, 35, 47, 120–121 ESRD Network Organization 53 Exception (Part D) 69, 90–91 Extra Help (Help Paying Medicare Drug Costs) 49, 62, 78–81, 116 Eye Exam 30, 31 Eyeglasses 30
F
Fecal Occult Blood Test 28, 40 Federal Employee Health Benefits Program 14, 24, 72 Federally-Qualified Health Center Services 31, 36 Flexible Sigmoidoscopy 26, 28, 40 Flu Shot 31, 40 Foot Exam 31 Formulary 44, 65, 69, 78 Fraud 94–97
G
Gap (Coverage) 65–66, 78 General Enrollment Period 18, 22–23 Glaucoma Test 31, 40
H
Health Care Proxy 103–104 Health Information Technology (Health IT) 123 Health Maintenance Organization (HMO) 43, 50, 55 Hearing Aids 31, 39 Help with Costs 49, 54, 78–84 Hepatitis B Shot 31, 40 HIV Screening 32 Home Health Care 16, 19, 32, 82, 89, 107–108, 120–121 Hospice Care 16, 19, 50, 120 Hospital Care (Inpatient Coverage) 16, 20, 30, 120
I
Identity Theft 94–95, 97 Immunizations 25, 31, 34–35, 40, 69 Indian Health Service 44, 52, 72 Institution 57–58, 63, 79, 81, 116
J
Join Medicare Drug Plan 43, 62–72, 79–80, 90–91, 122 Medicare Health Plan 52, 58–61
K
Kidney Dialysis 12, 18, 32, 52–53, 55, 57, 107–108 Kidney Transplant 12, 18, 33, 37, 53
L
Late Enrollment Penalty Part A 18 Part B 21–24 Part D 67, 78, 122 Lifetime Reserve Days 116, 120 Limited Income 49, 54, 78–84, 106 Living Will 103
Index
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NOTE: The page number shown in bold provides the most detailed information. L (continued)
Long-Term Care 20, 39, 61, 82, 100–102 Low-Income Subsidy (LIS) 49, 62, 78–81, 116
M
Mammogram 32, 40, 55, 57 Medicaid 57–58, 61, 63, 73, 79, 81–82, 101 Medical Equipment 19, 30, 32, 35, 47, 120–121 Medical Nutrition Therapy 33, 40 Medical Savings Account (MSA) Plans 56, 58, 62 Medically Necessary 21, 25, 30, 69, 100, 117 Medicare Part A 16–20, 43, 119–120 Part B 21–38, 43, 119, 121 Part C 43, 50–59, 122 Part D 43–44, 49, 62–72, 78–81, 90–91, 122 Medicare Advantage Plans (like an HMO or PPO) 43, 50–59, 87 Medicare Authorization to Disclose Personal Health Information 106 Medicare Beneficiary Ombudsman 98 Medicare Card (lost) 14, 17 Medicare Cost Plan 60 Medicare Prescription Drug Coverage 43–44, 49, 62–72, 78–81, 90–91, 122 Medicare Prescription Drug Plans (PDP) 43–44, 49, 62–72, 78–81, 90–91, 122 Medicare Savings Programs 79, 83 Medicare SELECT 74–75 Medicare Summary Notice (MSN) 46, 87, 92, 96–97 Medigap (Medicare Supplement Insurance) 23–24, 43, 45, 48, 52, 59, 71, 74–76 Mental Health Care 20, 33, 57, 120–121
N
Non-doctor 33 Nurse Practitioner 33 Nursing Home 57–58, 79, 81–82, 100–101, 104, 108 Nutrition Therapy Services 33, 40
O
Occupational Therapy 19, 32–33, 121 Office for Civil Rights 14, 93, 97 Office of Inspector General 14, 96–97 Office of Personnel Management 14, 72, 100 Ombudsman (Medicare Beneficiary) 98 Online 2, 59, 64, 80, 95, 107, 123 Original Medicare 13, 43, 45–49, 74–75, 87–89, 92–93, 120–121 Orthotic Items 35 Outpatient Hospital Services 34, 121 Oxygen 30, 106
P
Pap Test 34, 40, 55, 57 Part A 16–20, 43, 119–120 Part B 21–38, 39, 43, 119, 121 Part C 43, 50–59, 122 Part D 43–44, 49, 62–72, 78–81, 90–91, 122 Payment Options (premium) 70, 119 Pelvic Exam 34, 40, 55, 57 Penalty Part A 18 Part B 21–24 Part D 67, 78, 122 Personal Health Record 123 Physical Exam 26, 30, 34, 40 Physical Therapy 19–20, 32–34, 121 Physician Assistant 33 Pilot/Demonstration Programs 13, 61, 117 Pneumococcal Shot 35, 40 Power of Attorney 103 Preferred Provider Organization (PPO) Plan 43, 50, 55 Premium 16–18, 21, 43–45, 49–50, 54, 60, 65–67, 70, 75, 78–79, 83, 92, 96, 117, 119 Prescription Drugs 12, 35, 44–49, 55–57, 62–72, 78–82, 90–91, 115, 120 Preventive Services 25–36, 40, 106–107 Primary Care Doctor 45, 55–57, 117–118
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Index
NOTE: The page number shown in bold provides the most detailed information. P (continued)
S (continued)
Privacy Notice 92–93 Private Contract 48 Private Fee-for-Service (PFFS) Plans 56, 62 Programs of All-Inclusive Care for the Elderly (PACE) 61, 82, 101 Prostate Screening (PSA Test) 35, 40 Proxy (Health Care) 103–104 Publications 109 Pulmonary Rehabilitation 36
State Health Insurance Assistance Program (SHIP) 14, 42, 107–108, 110–113 State Medical Assistance (Medicaid) Office 61, 80, 82–83, 101, 106 State Pharmacy Assistance Program (SPAP) 82 Substance Abuse 33 Supplemental Policy (see Medigap) 23–24, 43, 45, 48, 52, 59, 71, 74–76 Supplemental Security Income (SSI) 79, 84 Supplies (medical) 19–20, 25, 29–36, 46–47, 86, 96, 106 Surgical Dressing Services 36
Q
Quality of Care 14, 44, 61, 105, 107–108, 123 Quality Improvement Organization (QIO) 14, 88, 105, 118
R
Railroad Retirement Board (RRB) 14, 17–18, 21–23, 46, 106, 119 Referral 26, 30, 34, 44–45, 50–51, 55–57, 118 Religious Nonmedical Health Care Institution 16 Replacing a Medicare Card 14, 17 Retiree Health Insurance 24, 43–45, 49, 52–53, 67, 71–73, 80, 100 Rights 86–93, 97–98 Rural Health Clinic 36
S
Second Surgical Opinions 36 Service Area 44, 52, 55, 58, 59, 63–64, 118 Shingles Vaccine 69 Shots (vaccinations) 25, 31, 34–35, 40, 69 Sigmoidoscopy 26, 28, 40 Skilled Nursing Facility (SNF) Care 16, 20, 36, 100, 115, 118, 120 Smoking Cessation 36, 40 SMP (Senior Medicare Patrol) Program 95 Social Security 14, 16–18, 21–23, 70, 80–81, 84, 94, 119 Special Enrollment Period 18, 22–24, 63, 71 Special Needs Plan (SNP) 53, 57 Speech-language Pathology 19, 32–33, 36, 121
T
Telehealth 37 Tests 27–29, 31–37 Tiers (drug formulary) 69, 90 Transplant Services 37 Travel 38, 44, 74 TRICARE 14, 24, 67, 72–73 TTY 14, 106, 118
U
Union 24, 43–45, 49, 52–53, 60, 63, 67, 71, 73, 80, 100 Urgently-Needed Care 38, 48, 50, 55, 57, 59
V
Vaccinations (shots) 25, 31, 34–35, 40, 69 Veterans’ Benefits (VA) 14, 67, 72 Vision 30–31, 50
W
Walkers 30, 106 Welcome to Medicare Physical Exam 26, 30, 34, 40 Wheelchairs 30, 106 www.medicare.gov 107 www.MyMedicare.gov 2, 40, 46, 87, 107
X
X-ray 32, 34, 36
What’s New and Important in 2010 ■■Mental Health—Lower costs for outpatient treatment. See page 33. ■■Medigap (Medicare Supplement Insurance) Policies—Plan changes. See page 74. ■■Children’s Health Insurance Program—Your children or grandchildren may qualify for health insurance through this expanded program. See page 84. ■■Caregiver Information—If you help someone with Medicare-related decisions, there are two new resources to help you get the information you need. See page 109. ■■Medicare Health and Prescription Drug Plans—Visit www.medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227) to find plans in your area. TTY users should call 1‑877‑486‑2048. ■■What You Pay for Medicare (Part A and Part B)—Costs are on pages 119–122. ■■New Ways to Manage Your Health Information—Exciting tools to help reduce paperwork and improve your quality of care. See page 123.
Coverage and Costs Change Yearly.
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to
7 1 2
be
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3 7 APRIL
Mark your calendar with these important dates! Your health, finances, or coverage may have changed in the last year. Look at what your coverage would be for next year and see if the cost, coverage, quality, and convenience meet your needs.
October 2009: Compare Your Medicare Coverage Choices Compare your coverage to others to see if there’s a better choice for you. See page 13. November 15, 2009–December 31, 2009: Stay or Switch You can switch your Medicare health or prescription drug coverage for 2010. See pages 58 and 63 for other times when you can switch your coverage. January 1, 2010: 2010 Coverage and Costs Begin New coverage begins if you switched. New costs and coverage changes also begin if you stay with your current coverage. At the end of the year, health and prescription drug plans can decide not to participate in Medicare. See page 59 and 64 for more information about your options.
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Medicare Basics What Is Medicare? Medicare is health insurance for the following: ■■People age 65 or older ■■People under age 65 with certain disabilities ■■People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
The Different Parts of Medicare The different parts of Medicare help cover specific services. Medicare has the following parts: Medicare Part A (Hospital Insurance) ■■ Helps cover inpatient care in hospitals ■■ Helps cover skilled nursing facility, hospice, and home health care See pages 16–20.
Medicare Part B (Medical Insurance) ■■ Helps cover doctors’ services, outpatient care, and home health care ■■ Helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse See pages 21–38.
Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO) ■■ A health coverage option run by private insurance companies approved by and under contract with Medicare ■■ Includes Part A, Part B, and usually other coverage like prescription drugs See pages 50–59.
Medicare Part D (Medicare Prescription Drug Coverage) ■■ A prescription drug option run by private insurance companies approved by and under contract with Medicare ■■ Helps cover the cost of prescription drugs ■■ May help lower your prescription drug costs and help protect against higher costs in the future See pages 62–72.
Medicare Basics Your Medicare Coverage Choices With Medicare, you can choose how you get your health and prescription drug coverage. Below are brief descriptions of your coverage choices. Section 2 has more details about these choices and information to help you decide. Original Medicare See pages 45–49. ■■Run by the Federal government. ■■Provides your Part A and/or Part B coverage. ■■You can go to any doctor or hospital that accepts Medicare. ■■You can join a Medicare Prescription Drug Plan to add drug coverage. ■■You can buy a Medigap (Medicare Supplement Insurance) policy (sold by private insurance companies) to help fill the gaps in Part A and Part B. Medicare Advantage Plans (like an HMO or PPO) See pages 50–59. ■■Run by private insurance companies approved by and under contract with Medicare. ■■Provides your Part A and Part B coverage but can charge different amounts for certain services. May offer extra coverage and prescription drug coverage, sometimes for an extra cost. Cost for items and services vary by plan. ■■If you want drug coverage, you must get it through your plan (in most cases). ■■You don’t need, and you can’t use a Medigap policy with a Medicare Advantage Plan. Other Medicare Health Plans See pages 60–61. ■■Plans that aren’t Medicare Advantage Plans but are still part of Medicare. ■■Include Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). ■■Most plans provide Part A and Part B coverage, and some also provide prescription drug coverage (Part D). Note: You might also have health and/or prescription drug coverage from a former or current employer or union that could affect your choices.
See page 43 for a chart that explains your Medicare coverage choices and the decisions you need to make.
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Medicare Basics Where to Get Your Medicare Questions Answered 1-800-MEDICARE To get general Medicare information and other important telephone numbers.
1-800-633-4227 TTY 1-877-486-2048
State Health Insurance Assistance Program (SHIP) To get free Medicare counseling and personalized help making coverage decisions; information on programs for people with limited income and resources; and help with claims, billing, and appeals.
See pages 110–113.
Social Security To replace a Medicare card; change your address or name; get information about Part A and/or Part B eligibility, entitlement, and enrollment; apply for Extra Help with Medicare prescription drug costs; ask questions about premiums; and report a death.
1-800-772-1213 TTY 1-800-325-0778
Coordination of Benefits Contractor To get information on whether Medicare or your other insurance pays first and to report changes in your insurance information.
1-800-999-1118 TTY 1-800-318-8782
Department of Defense To get information about the TRICARE Pharmacy Program.
1-877-363-1303 TTY 1-877-540-6261
Department of Health and Human Services Office of Inspector General If you suspect billing fraud.
1-800-447-8477 TTY 1-800-377-4950
Office for Civil Rights If you think you were discriminated against or if your health information privacy rights were violated.
1-800-368-1019 TTY 1-800-537-7697
Department of Veterans Affairs If you are a veteran or have served in the U.S. military.
1-800-827-1000 TTY 1-800-829-4833
Office of Personnel Management To get information about the Federal Employee Health Benefits Program for current and retired Federal employees.
1-888-767-6738 TTY 1-800-878-5707
Railroad Retirement Board (RRB) If you have benefits from the RRB, call them to change your address or name, check eligibility, enroll in Medicare, replace your Medicare card, and report a death.
Local RRB office or 1-877-772-5772
Quality Improvement Organization (QIO) To ask questions or report complaints about the quality of care for a Medicare-covered service or if you think your service is ending too soon.
Call 1-800-MEDICARE to get the telephone number for your QIO.
SECTION
1
Medicare Part A and Part B (What’s Covered)
T
his section has information that can help you make informed health care decisions. It also explains what Medicare Part A and Part B cover and how to enroll. Section 1 includes information about the following: Part A (Hospital Insurance) What is it and signing up . . . . . . . . . . . . . . . . . 16–18 Covered Services . . . . . . . . . . . . . . . . . . . . . 19–20 Part B (Medical Insurance) What is it and signing up . . . . . . . . . . . . . . . . . 21–25 Covered Services . . . . . . . . . . . . . . . . . . . . . 26–38 What’s NOT Covered by Part A and Part B? . . . . . . . . . . . 39 Preventive Services Checklist . . . . . . . . . . . . . . . . . . . 40
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Section 1—Medicare Part A and Part B (What’s Covered)
What Services Does Medicare Cover? Medicare covers certain medical services and supplies in hospitals, doctors’ offices, and other health care settings. Services are either covered under Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance). If you have both Part A and Part B, you can get all of the Medicare-covered services listed here, no matter what type of Medicare coverage you choose. See pages 19–20 for a list of services covered by Part A and some of the conditions you must meet. See pages 26–38 for the Part B-covered services list.
What Is Part A (Hospital Insurance)? Part A helps cover the following: ■■Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals) ■■Inpatient care in a skilled nursing facility (not custodial or long‑term care) ■■Hospice care services ■■Home health care services ■■Inpatient care in a Religious Nonmedical Health Care Institution (Medicare will only cover the non-medical, non-religious health care items and services in this type of facility for people who qualify for hospital or skilled nursing facility care but for whom medical care isn’t in agreement with their religious beliefs.) Blue words in the text are defined on pages 115–118.
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. If you aren’t eligible for premium-free Part A, you may be able to buy Part A if you meet one of the following conditions: ■■You are age 65 or older, and you are entitled to (or enrolling in) Part B and meet the citizenship or residency requirements. ■■You are under age 65, disabled, and your premium-free Part A coverage ended because you returned to work. Call Social Security at 1-800-772-1213 for more information about the Part A premium. TTY users should call 1-800-325-0778. Note: The premium amount for people who buy Part A is on page 119.
Section 1—Medicare Part A and Part B (What’s Covered)
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What Is Part A (Hospital Insurance)? (continued) In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B. See page 83. You can find out if you have Part A by looking at your Medicare card.
S
E L P AM
Note: Keep this card safe. If you have Original Medicare, you will use this card to get your Medicare-covered services. If you join a Medicare plan, you must use the card from the plan to get your Medicarecovered services.
Is Your Medicare Card Lost or Damaged? To order a new card, call Social Security at 1-800-772-1213, or visit www.socialsecurity.gov. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board (RRB), visit www.rrb.gov, and select “Benefit Online Services,” or call the RRB at 1-877-772-5772.
Signing Up for Part A Many People Automatically Get Part A If you get benefits from Social Security or the Railroad Retirement Board (RRB), you automatically get Part A starting the first day of the month you turn age 65. If you are under age 65 and disabled, you automatically get Part A after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You will get your Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability. If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), you automatically get Part A the month your disability benefits begin.
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Section 1—Medicare Part A and Part B (What’s Covered)
Signing Up for Part A (continued)
Blue words in the text are defined on pages 115–118.
Some People Need to Sign Up for Part A If you aren’t getting Social Security or RRB benefits (for instance, because you are still working), you will need to sign up for Part A (even if you are eligible to get it premium-free). You should contact Social Security 3 months before you turn age 65. If you worked for a railroad, contact the RRB to sign up. If you need to sign up for Part A, you can sign up during the following times: ■■Initial Enrollment Period—When you are first eligible for Medicare. (This is a 7-month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65.) ■■General Enrollment Period—Between January 1–March 31 each year. Your coverage will begin July 1. You may have to pay a higher premium for late enrollment. See below. ■■Special Enrollment Period—If you or your spouse (or family member if you are disabled) is currently working, and you are covered by a group health plan through the employer or union. See page 22. ■■Special Enrollment Period for International Volunteers—If you are serving as a volunteer in a foreign country. See page 22. If you aren’t eligible for premium-free Part A, you may be able to buy it. However, if you don’t buy Part A when you are first eligible, your monthly premium may go up 10%. You will have to pay the higher premium for twice the number of years you could have had Part A, but didn’t join. For example, if you were eligible for Part A, but didn’t join for 2 years, you will have to pay the higher premium for 4 years. You don’t have to pay a penalty if you are eligible for a special enrollment period. For more information on Part A, call Social Security, or visit www.socialsecurity.gov. If you get benefits from the RRB, call 1‑877‑772‑5772. If you have End-Stage Renal Disease (ESRD), different rules apply. Visit your local Social Security office, or call Social Security at 1‑800‑772‑1213 to sign up for Part A. TTY users should call 1‑800‑325-0778. For more information, visit www.medicare.gov/Publications/Pubs/pdf/10128.pdf to view the booklet, “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”
Section 1—Medicare Part A and Part B (What’s Covered)
Part A-Covered Services Blood
In most cases, the hospital gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
Home Health Services
Limited to medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment (see page 30), and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort.
Hospice Care
For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling. A Medicare-approved hospice usually gives hospice care in your home or other facility like a nursing home. Hospice care doesn’t include room and board unless the hospice medical team determines that you need short-term inpatient stays for pain and symptom management that can’t be addressed in the home. These stays must be in a Medicare-approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care which is care you get in a Medicare‑approved facility so that your usual caregiver can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness. You can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that you are terminally ill.
Copayments, coinsurance, and deductibles may apply for each service. See page 120 for specific costs and other information about these services.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part A-Covered Services Includes semi-private room, meals, general nursing, drugs as Hospital part of your inpatient treatment, and other hospital services and Stays (Inpatient) supplies. Examples include inpatient care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care. This doesn’t include private-duty nursing, a television or telephone in your room (if there is a separate charge for these items), or personal care items like razors or slipper socks. It also doesn’t include a private room, unless medically necessary. If you have Part B, it covers the doctor’s services you get while you are in a hospital. Skilled Nursing Facility Care
Includes semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies after a 3-day minimum inpatient hospital stay for a related illness or injury. An inpatient stay begins the day you are formally admitted with a doctor’s order to a hospital. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long-term care or custodial care in this setting.
Copayments, coinsurance, and deductibles may apply for each service. See page 120 for specific costs and other information about these services. If you join a Medicare Advantage Plan (like an HMO or PPO) or have other insurance (like a Medigap policy, or employer or union coverage), your costs may be different. Contact the plans you are interested in to find out about the costs.
Section 1—Medicare Part A and Part B (What’s Covered)
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What Is Part B (Medical Insurance)? Part B helps cover medically-necessary services like doctors’ services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. You can find out if you have Part B by looking at your Medicare card.
How Much Does It Cost? You pay the Part B premium each month. Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more. Your modified adjusted gross income is your adjusted gross income plus your tax exempt interest income. Social Security will notify you if you have to pay more than the standard premium. If you have to pay a higher amount for your Part B premium and you disagree (even if you get RRB benefits), call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. See page 119 to find out if your Part B premium will be higher based on your income. If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty. See page 23. If you have limited income and resources, see page 83 for information about help paying your Medicare premiums. See page 121 for other Part B costs.
How You Get Part B
Blue words in the text are defined on pages 115–118.
If you get benefits from Social Security or the Railroad Retirement Board (RRB), in most cases, you will automatically get Part B starting the first day of the month you turn age 65. If your birthday is on the first day of the month, your Part B will start the first day of the prior month. If you are under age 65 and disabled, you will automatically get Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You will get your Medicare card in the mail about 3 months before your 65th birthday or your 25th month of disability. If you don’t want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will pay Part B premiums.
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Section 1—Medicare Part A and Part B (What’s Covered)
How You Get Part B (continued) If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), you automatically get Part B the month your disability benefits begin.
When Can You Sign Up for Part B? If you didn’t sign up for Part B when you first became eligible, you may be able to sign up during one of these times: ■■General Enrollment Period—Between January 1–March 31 each year. Your coverage will begin on July 1. You may have to pay a late enrollment penalty. ■■Special Enrollment Period—If you wait to sign up for Part B because you or your spouse is currently working, and you are covered by a group health plan based on that work, or if you are disabled and you or a family member is working, and you are covered by a group health plan based on that work. You can sign up for Part B anytime while you have group health plan coverage based on current employment or during the 8-month period that begins the month after the employment ends, or the group health plan coverage ends, whichever happens first. If you have COBRA coverage, you must enroll during the 8‑month period that begins the month after the employment ends. This Special Enrollment Period doesn’t apply to people with End‑Stage Renal Disease (ESRD). ■■Special Enrollment Period for International Volunteers—If you waited to sign up for Part B because you had health insurance while volunteering outside of the U.S. for a tax exempt organization for at least a year. You can sign up during the 6-month period that begins the first month that any one of the following happens: 1. You are no longer volunteering outside the U.S. 2. The sponsoring organization is no longer tax exempt. 3. You no longer have health insurance coverage outside the U.S.
Section 1—Medicare Part A and Part B (What’s Covered)
When Can You Sign Up for Part B? (continued) If you have Medicare because of End-Stage Renal Disease (ESRD), you can sign up for Part B when you sign up for Part A. See page 18. If you delay signing up for Part B, you can only get it during the general enrollment period, and you may have to pay a late enrollment penalty. If you live in Puerto Rico, and you want Part B, you will need to sign up for it. Contact your local Social Security office for more information. If you aren’t getting Social Security or RRB benefits, and you want to get Part B, you will need to sign up for Part B during your initial enrollment period (the 7-month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65). If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it. Usually, you don’t pay a late enrollment penalty if you sign up for Part B during a special enrollment period. Note: If you are age 65 or older, after you sign up for Part B, you have a 6-month Medigap open enrollment period which gives you a guaranteed right to buy a Medigap (Medicare Supplement Insurance) policy. Once this period starts, it can’t be delayed or replaced. See page 75.
Blue words in the text are defined on pages 115–118.
Call Social Security at 1-800-772-1213 for more information about your Medicare eligibility and to sign up for Part B. TTY users should call 1-800-325-0778. If you get RRB benefits, call the RRB at 1‑877‑772‑5772. For general information about enrolling, visit www.medicare.gov, and select “Find Out if You Are Eligible for Medicare and When You Can Enroll.” You can also get free, personalized health insurance counseling from your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number.
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Section 1—Medicare Part A and Part B (What’s Covered)
Medicare and TRICARE Coverage If you have Medicare Part A and TRICARE (coverage for active‑duty military or retirees and their families), you must have Part B to keep your TRICARE coverage. However, if you are an active‑duty service member, or the spouse or dependent child of an active‑duty service member, the following applies to you: ■■You don’t have to enroll in Part B to keep your TRICARE coverage while the service member is on active duty. ■■When the active-duty service member retires, you must enroll in Part B to keep your TRICARE coverage. ■■You can get Part B during a special enrollment period if you have Medicare because you are age 65 or older, or you are disabled. Note: If you are in a Medicare Advantage Plan or choose to join a plan, tell the plan that you have TRICARE, so your bills can be paid correctly.
Part B and Employer or Union Coverage Having coverage through an employer (including the Federal Employee Health Benefits Program) or union while you or your spouse is still working can affect your Part B enrollment rights. You should contact your employer or union benefits administrator to find out how your insurance works with Medicare and if it would be to your advantage to delay Part B enrollment. When the employment ends, three things happen: 1. You may get a chance to elect COBRA coverage, which continues your health coverage through the employer’s plan (in most cases for only 18 months) and probably at a higher cost to you. 2. You may get a special enrollment period to sign up for Part B without a penalty. This period will run for 8 months and begins the month after your employment ends. This period will run whether or not you elect COBRA. If you elect COBRA, don’t wait until your COBRA ends to enroll in Part B. If you enroll in Part B after the 8‑month special enrollment period, you may have to pay a late enrollment penalty. 3. When you sign up for Part B, you have a 6-month Medigap open enrollment period which gives you a guaranteed right to buy a Medigap (Medicare Supplement Insurance) policy. Once this period starts, it can’t be delayed or repeated. See page 75.
Section 1—Medicare Part A and Part B (What’s Covered)
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Part B-Covered Services There are two kinds of Part B-covered services: Medically-necessary services—Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services—Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best (for example, Pap tests, flu shots, and colorectal cancer screenings). Use the chart on page 40 to talk to your doctor or other health care provider about Medicare’s preventive services, and ask which services you need. You will see this symbol next to the preventive services on the following pages. Pages 26–38 include an alphabetical list of common services that Medicare Part B covers. To find out if Medicare covers a service not on this list, visit www.medicare.gov, and select “Find Out What Medicare Covers,” or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
What You Pay
Blue words in the text are defined on pages 115–118.
Costs for Part B services depend on whether you have Original Medicare or are in a Medicare health plan. The charts on the following pages give general information about what you must pay if you have Original Medicare. For some services, there are no costs, but you may have to pay for the visit to the doctor. If the Part B deductible applies, you must pay all costs until you meet the yearly Part B deductible before Medicare begins to pay its share. See page 121 for the Part B deductible amount. Then, after your deductible is met, you typically pay 20% of the Medicare-approved amount of the service. You can save money if you choose doctors or providers who accept assignment. See page 47. You also may be able to save money on your Medicare costs if you have limited income and resources. See pages 78–84. If you join a Medicare Advantage Plan (like an HMO or PPO) or have other insurance (like a Medigap policy, or employer or union coverage), your costs may be different. Contact the plans you are interested in to find out about the costs.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Abdominal Aortic Aneurysm Screening
A one-time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your one-time “Welcome to Medicare” physical exam. See “Physical Exam.” You pay 20% of the Medicare‑approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.
Ambulance Services
Emergency ground transportation when you need to be transported to a hospital or skilled nursing facility for medically‑necessary services, and transportation in any other vehicle could endanger your health. Medicare will pay for transportation in an airplane or helicopter if you require immediate and rapid ambulance transportation that ground transportation can’t provide. In some cases, Medicare may pay for limited non-emergency transportation if you have orders from your doctor. Medicare will only cover services to the nearest appropriate medical facility that is able to give you the care you need. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Ambulatory Surgical Centers
Facility fees for approved surgical procedures provided in an ambulatory surgical center (facility where surgical procedures are performed, and the patient is released within 24 hours). You pay 20% of the Medicare-approved amount (except for screening flexible sigmoidoscopies and screening colonoscopies, for which you pay 25%), and the Part B deductible applies. You pay all facility charges for procedures Medicare doesn’t allow in ambulatory surgical centers.
Blood
In most cases, the provider gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121.
Section 1—Medicare Part A and Part B (What’s Covered)
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Part B-Covered Services Bone Mass Measurement (Bone Density)
Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
NEW
Medicare covers comprehensive programs that include exercise, education, and counseling for patients who meet certain conditions with a doctor’s referral. Medicare also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. You pay 20% of the Medicare-approved amount if you get the services in a doctor’s office. In a hospital outpatient setting, you pay a copayment.
Cardiac Rehabilitation
Cardiovascular Screenings
Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the test, but you generally have to pay 20% of the Medicare‑approved amount for the doctor’s visit.
Chiropractic Services (limited)
Helps correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Note: You pay all costs for any services or tests ordered by a chiropractor.
Clinical Laboratory Services
Includes certain blood tests, urinalysis, some screening tests, and more. No cost to you.
Clinical Research Studies
Clinical research studies test different types of medical care, like how well a cancer drug works. They help doctors and researchers see if the new care works and if it’s safe. Medicare covers some costs, like doctor visits and tests, in qualifying clinical research studies. You pay 20% of the Medicareapproved amount, and the Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121. Medicare may cover some services and tests more often than the timeframes listed if needed to diagnose a condition.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Colorectal Cancer Screenings
To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor. ■■ Fecal Occult Blood Test—Once every 12 months if age 50 or older. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit. ■■ Flexible Sigmoidoscopy—Generally, once every 48 months if age 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. ■■ Colonoscopy—Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. You pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. ■■ Barium Enema—Once every 48 months if age 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare-approved amount.
Defibrillator (Implantable Automatic)
For some people diagnosed with heart failure. You pay 20% of the Medicare-approved amount for the doctor’s services. You pay a copayment but no more than the Part A hospital stay deductible (see page 120) if you get the device as a hospital outpatient. The Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121. Medicare may cover some services and tests more often than the timeframes listed if needed to diagnose a condition.
Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Diabetes Screenings
Checks for diabetes. Medicare covers these screenings if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests are also covered if you answer yes to two or more of the following questions: ■■ Are you age 65 or older? ■■ Are you overweight? ■■ Do you have a family history of diabetes (parents, siblings)? ■■ Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds? Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.
Diabetes Self‑Management Training
For people with diabetes. Your doctor or other health care provider must provide a written order. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Diabetes Supplies Including blood sugar testing monitors, blood sugar test
strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Insulin is covered only if used with an insulin pump. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Note: Insulin and certain medical supplies used to inject insulin, such as syringes, may be covered by Medicare prescription drug coverage (Part D).
Part B deductible and coinsurance amounts are on page 121.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Doctor Services
Services that are medically necessary (includes outpatient and some doctor services you get when you are a hospital inpatient) or covered preventive services. Doesn’t cover routine physicals except for the one-time “Welcome to Medicare” physical exam. See “Physical Exam.” You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Durable Medical Equipment (like walkers)
Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds your doctor orders for use in the home. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. You must get your covered equipment or supplies from a supplier enrolled in Medicare. You should also check if the supplier is a participating supplier. Participating suppliers must accept assignment (see page 47), and your out‑of‑pocket costs may be less.
NEW
Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time “Welcome to Medicare” physical exam. See “Physical Exam.” You pay 20% of the Medicare-approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test. See page 37.
EKG Screening
Emergency Department Services
When you believe your health is in serious danger. You may have a bad injury, a sudden illness, or an illness that quickly gets much worse. You pay a specified copayment for the hospital emergency department visit, and you pay 20% of the Medicare-approved amount for the doctor’s services. The Part B deductible applies.
Eye Exams for People with Diabetes
Checks for diabetic retinopathy once every 12 months by an eye doctor who is legally allowed by the state to do the test. You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Eyeglasses (limited)
One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121.
Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services FederallyQualified Health Center Services Flu Shots
Includes many outpatient primary care and preventive services you get through certain community-based organizations. You pay 20% of the Medicare-approved amount.
Foot Exams and Treatment
If you have diabetes-related nerve damage and/or meet certain conditions. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Glaucoma Tests
Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you pay a copayment.
Hearing and Balance Exams
If your doctor orders it to see if you need medical treatment. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Helps prevent influenza or flu virus. Covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor accepts assignment for giving the shot.
Note: Medicare doesn’t cover hearing aids and exams for fitting hearing aids.
Hepatitis B Shots
Helps protect people from getting Hepatitis B. This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End‑Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare‑approved amount for shots given in a doctor’s office, and the Part B deductible applies. You pay a copayment for a Hepatitis B shot given in a hospital outpatient setting.
Part B deductible and coinsurance amounts are on page 121.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services NEW HIV Screening
Starting December 8, 2009, Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. There is no cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.
Home Health Services
Limited to medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order it, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort. No cost to you for home health services. For Medicare-covered durable medical equipment, you pay 20% of the Medicare‑approved amount, and the Part B deductible applies.
Kidney Dialysis Services and Supplies
For people with End-Stage Renal Disease (ESRD). Medicare covers dialysis either in a facility or at home when your doctor orders it. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
NEW
Medicare may cover kidney disease education services if you have kidney disease, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Kidney Disease Education Services Mammograms (screening)
A type of X-ray to check women for breast cancer before they or their doctor may be able to find it. Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39. You pay 20% of the Medicare-approved amount.
Part B deductible and coinsurance amounts are on page 121. Medicare may cover some services and tests more often than the timeframes listed if needed to diagnose a condition.
Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Medical Nutrition Therapy Services
Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Mental Health Care (outpatient)
To get help with mental health conditions such as depression, anxiety, or substance abuse. Includes services generally given outside a hospital or in a hospital outpatient setting, including visits with a doctor, psychiatrist, clinical psychologist, or clinical social worker, and lab tests. Certain limits and conditions apply. What you pay will depend on whether you are being diagnosed and monitored or whether you are getting treatment. ■■ For visits to a doctor or other health care provider to diagnose your condition, or to monitor or change your prescriptions, you pay 20% of the Medicare-approved amount. ■■ For outpatient treatment of your condition (such as counseling or psychotherapy), you pay 45% in 2010 (which is lower than in 2009) of the Medicare-approved amount. This coinsurance amount will continue to decrease over the next 4 years. In a hospital outpatient setting, you pay a copayment. The Part B deductible applies for both visits to diagnose or monitor your condition as well as treatment. Note: Inpatient mental health care is covered under Part A hospital stays. See page 20. Talk to your doctor if you feel sad, have little interest in things you used to enjoy, feel dependent on drugs or alcohol, or have thoughts about ending your life.
Non-doctor Services
Medicare covers services provided by non-doctors, such as physician assistants and nurse practitioners. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Occupational Therapy
Evaluation and treatment to help you return to usual activities (such as dressing or bathing) after an illness or accident when your doctor certifies you need it. There may be limits on physical therapy, occupational therapy, and speech-language pathology services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Outpatient Hospital Services
Services you get as an outpatient as part of a doctor’s care. You pay 20% of the Medicare-approved amount for the doctor’s services. You may pay more for a doctor’s care in a hospital outpatient setting than you will pay for the same care in a doctor’s office. You pay a specified copayment for each service you get in an outpatient hospital setting. The copayment can’t be more than the Part A hospital stay deductible. See page 120. The Part B deductible applies.
Outpatient Medical and Surgical Services and Supplies
For approved procedures (like X-rays, a cast, or stitches). You pay 20% of the Medicare-approved amount for the doctor’s services. You pay a copayment for each service you get in an outpatient hospital setting. For each service, this amount can’t be more than the Part A hospital stay deductible. See page 120. The Part B deductible applies, and you pay all charges for items or services that Medicare doesn’t cover.
Pap Tests and Pelvic Exams (includes clinical breast exam)
Checks for cervical, vaginal, and breast cancers. Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. You pay 20% of the Medicare-approved amount for Pap test specimen collection, and pelvic and breast exams. If the pelvic exam was provided in a hospital outpatient setting, you pay a copayment.
Physical Exam (one-time “Welcome to Medicare” physical exam)
A one-time review of your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. You pay 20% of the Medicare-approved amount. In a hospital outpatient setting, you pay a copayment. When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare” physical exam. Evaluation and treatment for injuries and diseases that change your ability to function when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Physical Therapy
Part B deductible and coinsurance amounts are on page 121.
Section 1—Medicare Part A and Part B (What’s Covered)
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Part B-Covered Services Pneumococcal Shot
Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.
Prescription Drugs (limited)
Includes a limited number of drugs such as injections you get in a doctor’s office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or infusion pump) and under very limited circumstances, certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicareapproved amount for these covered drugs. If the covered drugs you get in a hospital outpatient setting are part of the service you get, you pay the copayment for the services. However, if you get other types of drugs in a hospital outpatient setting, what you pay depends on whether you have Part D or other prescription drug coverage, whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting. Keep in mind that under Part B, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage. See page 69 for more information.
Prostate Cancer Screenings
Helps detect prostate cancer. Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you pay a copayment. You pay nothing for the PSA test. Including arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); some types of breast prostheses (after mastectomy); and prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) when your doctor orders it. For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Prosthetic/ Orthotic Items
Part B deductible and coinsurance amounts are on page 121.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services NEW Pulmonary Rehabilitation
Medicare covers a comprehensive program of pulmonary rehabilitation if you have moderate to very severe chronic obstructive pulmonary disease (COPD) and have a referral for pulmonary rehabilitation from the doctor treating your chronic respiratory disease. You pay 20% of the Medicareapproved amount if you get the service in a doctor’s office. You pay a copayment per session if you get the service in a hospital outpatient setting.
Rural Health Clinic Services
Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.
Second Surgical Opinions
Covered in some cases for surgery that isn’t an emergency. In some cases, Medicare covers third surgical opinions. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Smoking Cessation (counseling to stop smoking)
Includes up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Speech-Language Pathology Services
Evaluation and treatment given to regain and strengthen speech and language skills including cognitive and swallowing skills when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Surgical Dressing Services
For treatment of a surgical or surgically-treated wound. You pay 20% of the Medicare-approved amount for the doctor’s services. You pay a fixed copayment for these services when you get them in a hospital outpatient setting. You pay nothing for the supplies. The Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121.
Section 1—Medicare Part A and Part B (What’s Covered)
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Part B-Covered Services Telehealth
Includes a limited number of medical or other health services, like office visits and consultations provided using an interactive two-way telecommunications system (like real-time audio and video) by an eligible provider who is at a location different from the patient’s. Available in some rural areas, under certain conditions, and only if the patient is located at one of the following places: a doctor’s office, hospital, rural health clinic, federally-qualified health center, hospital-based dialysis facility, skilled nursing facility, or community mental health center. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Tests
Including X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. See “Clinical Laboratory Services” on page 27 for other Part B-covered tests. If you get the test at a hospital as an outpatient, you pay a copayment that may be more than 20% of the Medicare-approved amount, but it can’t be more than the Part A hospital stay deductible. See page 120.
Including doctor services for heart, lung, kidney, pancreas, Transplants and Immunosuppressive intestine, and liver transplants under certain conditions and only in a Medicare-certified facility. Medicare covers bone marrow Drugs and cornea transplants under certain conditions.
Immunosuppressive drugs are covered if Medicare paid for the transplant, or an employer or union group health plan that was required to pay before Medicare paid for the transplant. You must have been entitled to Part A at the time of the transplant, and you must be entitled to Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you are thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan’s network. Also, check the plan’s coverage rules for prior authorization. Note: Medicare drug plans (Part D) may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.
Part B deductible and coinsurance amounts are on page 121.
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Section 1—Medicare Part A and Part B (What’s Covered)
Part B-Covered Services Travel (health care needed when traveling outside the United States) (limited)
Medicare generally doesn’t cover health care while you are traveling outside the U.S. (the “U.S.” includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following situations: 1) If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition 2) If 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 3) If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
UrgentlyNeeded Care
To treat a sudden illness or injury that isn’t a medical emergency. You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies.
Part B deductible and coinsurance amounts are on page 121.
Section 1—Medicare Part A and Part B (What’s Covered)
What’s NOT Covered by Part A and Part B? Medicare doesn’t cover everything. If you need certain services that Medicare doesn’t cover, you will have to pay out-of-pocket unless you have other insurance to cover the costs. Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance, and copayments.
Blue words in the text are defined on pages 115–118.
Items and services that Medicare doesn’t cover include, but aren’t limited to, long-term care (see page 100), routine dental care, dentures, cosmetic surgery, acupuncture, hearing aids, and exams for fitting hearing aids. To find out if Medicare covers a service you need, visit www.medicare.gov, and select “Find Out What Medicare Covers,” or call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.
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Section 1—Medicare Part A and Part B (What’s Covered)
Preventive Services Checklist Take this checklist to your doctor or other health care provider, and ask which preventive services are right for you. You can also keep track of your preventive services by visiting www.MyMedicare.gov. See page 107. Medicare-covered Preventive Service Abdominal Aortic Aneurysm Screening Bone Mass Measurement Cardiovascular Screenings Colorectal Cancer Screenings Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Barium Enema Diabetes Screenings Diabetes Self-management Training EKG Screening Flu Shots Glaucoma Tests Hepatitis B Shots HIV Screening Mammogram (screening) Medical Nutrition Therapy Services Pap Test and Pelvic Exam (includes breast exam) Physical Exam (one-time “Welcome to Medicare” physical exam) Pneumococcal Shot Prostate Cancer Screenings Smoking Cessation (counseling to stop smoking)
Details on Page 26
Notes
27 27 28 28 28 28 28 29 29 30 31 31 31 32 32 33 34 34 35 35 36
For some services, you will need to wait a full 12 or 24 months before getting the service again. See the page numbers listed for more information.
SECTION
2
Your Medicare Choices
Y
ou have choices for how you get your Medicare health and prescription drug coverage. Before making any decisions, learn as much as you can about the types of coverage available to you. Section 2 includes information about the following: Decide How to Get Your Medicare . . . . . . . . . . . . . . 42–44 Original Medicare . . . . . . . . . . . . . . . . . . . . . . . 45–49 Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . 50–59 Other Medicare Health Plans . . . . . . . . . . . . . . . . . 60–61 Medicare Prescription Drug Coverage (Part D) . . . . . . . 62–72 Who Pays First When You Have Other Insurance . . . . . . .
73
Medigap (Medicare Supplement Insurance) Policies . . . . 74–76 This handbook has basic information. You will need more detailed information than this handbook provides to make a choice. See page 42 to get help with your Medicare decisions.
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Section 2—Your Medicare Choices
Decide How to Get Your Medicare You can choose different ways to get your Medicare coverage. If you choose Original Medicare and you want drug coverage, you must join a Medicare Prescription Drug Plan (Part D). If you choose to join a Medicare Advantage Plan, the plan may include Medicare prescription drug coverage. In most cases, if you don’t make a choice, you will have Original Medicare. See the next page for more information about your coverage choices and the decisions you need to make. Note: If you have End-Stage Renal Disease (ESRD), you will usually get your health care through Original Medicare. See page 53 for more information. Each year you should review your health and prescription needs because your health, finances, or plan’s coverage may have changed. If you decide other coverage will better meet your needs, you can switch plans during certain times. See pages 58 and 63. If you are satisfied with your current plan’s coverage for the following year, you don’t need to change plans.
Need Help Deciding?
Blue words in the text are defined on pages 115–118.
1. Visit www.medicare.gov, and select “Compare Health Plans and Medigap Policies in Your Area” or “Compare Medicare Prescription Drug Plans.” 2. Get free personalized counseling about choosing coverage. See pages 110–113 for the telephone number of your State Health Insurance Assistance Program (SHIP). 3. Call 1-800-MEDICARE (1-800-633-4227), and say “Agent.” TTY users should call 1-877-486-2048. If you need help in a language other than English or Spanish, let the customer service representative know. Note: The Medicare plan you join will use and release your personal information to other entities as permitted or required by law including for treatment, payment, health care operations, and for research and other purposes. See pages 92–93 to find out more about how Original Medicare uses and releases your personal information. If you have a Medicare Advantage Plan, contact your plan.
Section 2—Your Medicare Choices
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There are Two Main Choices for How You Get Your Medicare Use These Steps to Help You Decide Decide if You Want Original Medicare or a Medicare Advantage Plan
Original Medicare
Part A (Hospital Insurance) and Part B (Medical Insurance)
■■ Medicare provides this coverage. ■■ You have your choice of doctors, hospitals, and other providers. ■■ Generally, you or your supplemental coverage pay deductibles and coinsurance. ■■ You usually pay a monthly premium for Part B. See pages 45–49.
Step 2 Decide If You Want Prescription Drug Coverage (Part D) ■■ If you want this coverage, you must choose and join a Medicare Prescription Drug Plan. ■■ These plans are run by private companies approved by Medicare. See pages 62–72.
Step 3 Decide If You Want Supplemental Coverage ■■ You may want to get coverage that fills gaps in Original Medicare coverage. You can choose to buy a Medigap (Medicare Supplement Insurance) policy from a private company. ■■ Costs vary by policy and company. ■■ Employers/unions may offer similar coverage. See pages 74–76.
Medicare Advantage Plan (like an HMO or PPO)
Part C—Includes BOTH Part A (Hospital Insurance) and Part B (Medical Insurance)
■■ Private insurance companies approved by Medicare provide this coverage. ■■ In most plans, you need to use plan doctors, hospitals, and other providers, or you pay more or all of the costs. ■■ You usually pay a monthly premium (in addition to your Part B premium) and a copayment or coinsurance for covered services. ■■ Costs, extra coverage, and rules vary by plan. See pages 50–59.
Step 2 Decide If You Want Prescription Drug Coverage (Part D) ■■ If you want prescription drug coverage, and it’s offered by your plan, in most cases you must get it through your plan. ■■ In some types of plans that don’t offer drug coverage, you can choose and join a Medicare Prescription Drug Plan. See pages 55–57. Note: If you join a Medicare Advantage Plan, you don’t need a Medigap policy. If you already have a Medigap policy, you can’t use it to pay for out-of-pocket costs you have under the Medicare Advantage Plan. If you already have a Medicare Advantage Plan, you can’t be sold a Medigap policy. See pages 74–76.
In addition to Original Medicare or a Medicare Advantage Plan, you may be able to join other types of Medicare health plans. See pages 60–61. You may be able to save money or have other choices if you have limited income and resources. See pages 77–84. You may also have other coverage, like employer or union, military, or Veterans’ benefits. See pages 71–72.
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Section 2—Your Medicare Choices
Things to Consider When Choosing or Changing Your Coverage
Blue words in the text are defined on pages 115–118.
■■Coverage—Are the services you need covered? ■■Your other coverage—Do you have, or are you eligible for, other types of health or prescription drug coverage? If so, read the materials you get from your insurer or plan, or call them to find out how the coverage works with, or is affected by, Medicare. If you have coverage through a former or current employer or union, or get your health care from an Indian Health or Tribal Health Program, talk to your benefits administrator, insurer, or plan before making any changes to your coverage. ■■Cost—How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out‑of‑pocket for medical services? Your costs vary and may be different if you don’t follow the coverage rules. ■■Doctor and hospital choice—Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals? ■■Prescription drugs—What are your drug needs? Do you need to join a Medicare drug plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary (drug list)? ■■Quality of care—The quality of care and services given by plans and other health care providers can vary. Medicare has information to help you compare plans and providers. See page 108. ■■Convenience—Where are the doctors’ offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records or prescribe electronically? See page 123. ■■Travel—Will the plan cover you in another state? If you are in a Medicare plan, review the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) your plan sends you each year. The EOC gives you details about what the plan covers, how much you pay, and more. The ANOC includes any changes in coverage, costs, or service area that will be effective in January. If you don’t get an EOC or ANOC, contact your plan.
Section 2—Your Medicare Choices Original Medicare
Original Medicare Original Medicare is one of your health coverage choices as part of the Medicare Program. You will be in Original Medicare unless you choose a Medicare health plan. How Does It Work? Original Medicare is fee-for-service coverage (generally, there is a cost for each service). The Federal government manages it. Here are the general rules for how it works: Original Medicare Can I get my health care from any doctor or hospital?
Yes. You can go to any doctor, supplier, hospital, or other facility that is enrolled in Medicare and is accepting new Medicare patients.
Are prescription drugs covered?
With a few exceptions (see pages 20 and 35), most prescriptions aren’t covered. You can add comprehensive drug coverage by joining a Medicare Prescription Drug Plan (Part D).
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to see a specialist?
No.
Do I need a supplemental policy?
You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medigap (Medicare Supplement Insurance) policy.
What else do I need to know about Original Medicare?
■■ You generally pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance/ copayment) for covered services and supplies. See pages 120–121 to find out what you pay. ■■ You usually pay a monthly premium for Part B. See page 119. See page 83 for more information about Medicare Savings Programs. ■■ You generally don’t need to file Medicare claims. The law requires providers (like doctors, hospitals, skilled nursing facilities, and home health agencies) and suppliers to file Medicare claims for the covered services and supplies you get.
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Section 2—Your Medicare Choices Original Medicare
What You Pay Your out-of-pocket costs in Original Medicare depend on the following: ■■Whether you have Part A and/or Part B (most people have both). ■■Whether your doctor or supplier accepts “assignment.” See the next page. ■■Whether you and your doctor sign a private contract. See page 48. ■■The type of health care you need and how often you need it. ■■Whether you choose to get services or supplies Medicare doesn’t cover. If you do, you pay all the costs for these services. ■■Whether you have other health insurance that works with Medicare. ■■Whether you have Medicaid or get state help paying your Medicare costs. ■■Whether you have a Medigap (Medicare Supplement Insurance) policy. For more information on who pays first when you have other insurance, see page 73. For more information about help to cover the costs that Original Medicare doesn’t cover, see pages 74–83.
Medicare Summary Notices If you get a Medicare-covered service, you will get a Medicare Summary Notice (MSN) in the mail. The MSN shows all the services or supplies that providers and suppliers billed to Medicare during each 3-month period, what Medicare paid, and what you may owe the provider. The MSN isn’t a bill. When you get your MSN, read it carefully and do the following: ■■If you have other insurance, check to see if it covers anything that Medicare didn’t. ■■Keep your receipts and bills, and compare them to your MSN to be sure you got all the services, supplies, or equipment listed. See page 96 for information on billing fraud. ■■If you paid a bill before you got your MSN, compare your MSN with the bill to make sure you paid the right amount for your services. ■■If an item or service is denied, call your doctor’s office to make sure the claim is coded correctly. If not, the office can resubmit. If you want to file an appeal, see page 87. MSNs are mailed every 3 months. If Medicare owes you a refund, the MSN will be mailed as soon as the claim is processed. If you need to change your address on your MSN, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. If you get RRB benefits, call the RRB at 1-877-772-5772. Visit www.MyMedicare.gov to track your Medicare claims. See page 107.
Section 2—Your Medicare Choices Original Medicare
Keeping Your Costs Down (“Assignment” in Original Medicare) Assignment means that your doctor, provider, or supplier has signed an agreement with Medicare to accept the Medicare‑approved amount as full payment for covered services. Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. You may also want to find out how much you have to pay for each service or supply before you get it. In some cases they must accept assignment, like when they have a participation agreement with Medicare and give you Medicarecovered services. Here’s what happens if your doctor, provider, or supplier accepts assignment: ■■Your out-of-pocket costs may be less. ■■They agree to only charge you the Medicare deductible and coinsurance amount and wait for Medicare to pay its share. ■■They have to submit your claim to Medicare directly. They can’t charge you for submitting the claim.
Blue words in the text are defined on pages 115–118.
Here’s what happens if your doctor, provider, or supplier doesn’t accept assignment: ■■They still must submit a claim to Medicare when they give you Medicare-covered services. If they don’t submit the claim, ask them to file a Medicare claim for your services. If they still don’t file your claim, call 1-800-MEDICARE (1‑800-633-4227). TTY users should call 1-877-486-2048. You might have to pay the entire charge at the time of service, and then submit your claim to Medicare to get paid back. ■■They may charge you more than the Medicare-approved amount, but there is a limit called “the limiting charge.” They can only charge you up to 15% over the Medicare-approved amount. The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment. To find doctors and suppliers who accept assignment (participate in Medicare), visit www.medicare.gov and select “Find a Doctor or Other Healthcare Professional” or “Find Suppliers of Medical Equipment in Your Area.” You can also call 1-800-MEDICARE.
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Section 2—Your Medicare Choices Original Medicare
What Is a Private Contract? A “private contract” is a written agreement between you and a doctor or other health care provider who has decided not to provide services to anyone through Medicare. The private contract only applies to the services provided by the doctor or other provider who asked you to sign it. You don’t have to sign a private contract. You can always go to another doctor who does provide services through Medicare. If you sign a private contract with your doctor or other provider, the following rules apply: ■■Medicare won’t pay any amount for the services you get from this doctor or other provider. ■■You will have to pay the full amount of whatever this doctor charges you for the services you get. ■■If you have a Medigap (Medicare Supplement Insurance) policy, it won’t pay anything for the services you get. Call your Medigap insurance company before you get the service if you have questions. ■■Your doctor must tell you if the service is one that Medicare would pay for if you got it from another doctor who accepts Medicare. ■■Your doctor must tell you if he or she has been excluded from Medicare. You can’t be asked to sign a private contract for emergency or urgent care. You are always free to get services not covered by Medicare if you choose to pay for a service yourself. You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider. See pages 110–113 for the telephone number. See pages 86–98 for information about your appeal rights and how to protect yourself and Medicare from fraud.
Section 2—Your Medicare Choices Original Medicare
Adding Medicare Drug Coverage (Part D) In Original Medicare, if you don’t already have creditable prescription drug coverage and you would like prescription drug coverage, you must join a Medicare Prescription Drug Plan. These plans are available through private companies approved by and under contract with Medicare. If you don’t currently have creditable prescription drug coverage, you should think about joining a Medicare Prescription Drug Plan as soon as you are eligible. If you don’t join a Medicare Prescription Drug Plan when you are first eligible and you decide to join later, you may have to pay a late enrollment penalty. See pages 62–72 for more information. If you have creditable prescription drug coverage, call your employer or union’s benefits administrator before you make any changes to your coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependants.
Extra Help Paying for Drug Coverage Blue words in the text are defined on pages 115–118.
People with limited income and resources may qualify for Extra Help paying their Medicare prescription drug coverage costs. If you automatically qualify for Extra Help, you won’t pay a premium if you join certain Medicare drug plans. If you don’t automatically qualify, you may still get help to pay your prescription drug costs. See pages 78–81 to find out if you may qualify for Extra Help.
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Section 2—Your Medicare Choices Medicare Advantage Plans
Medicare Advantage Plans (Part C) A Medicare Advantage Plan (like an HMO or PPO) is another health coverage choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. In all plan types, you are always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you are in a Medicare Advantage Plan. Medicare Advantage Plans aren’t considered supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to your Part B premium, you usually pay one monthly premium for the services provided. Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan). Medicare Advantage Plans include the following: ■■Health Maintenance Organization (HMO) Plans. See page 55. ■■Preferred Provider Organization (PPO) Plans. See page 55. ■■Private Fee-for-Service (PFFS) Plans. See page 56. ■■Medical Savings Account (MSA) Plans. See page 56. ■■Special Needs Plans (SNP). See page 57. Make sure you understand how a plan works before you join. See pages 55–57 for more information about Medicare Advantage Plan types.
Section 2—Your Medicare Choices Medicare Advantage Plans Medicare Advantage Plans include the following: (continued) There are other less common types of Medicare Advantage Plans that may be available: ■■Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost. ■■Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan. Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs. Find out what types of plans are available in your area by visiting www.medicare.gov and selecting “Compare Health Plans and Medigap Policies in Your Area.” You can also call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048. Contact the plans you are interested in to get more information.
More About Medicare Advantage Plans
Blue words in the text are defined on pages 115–118.
■■As with Original Medicare, you still have Medicare rights and protections, including the right to appeal. See pages 86–89. ■■Check with the plan before you get a service to find out whether they will cover the service and what your costs may be. ■■You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan. ■■You can join a Medicare Advantage Plan even if you have a pre‑existing condition, except for End-Stage Renal Disease. ■■You can only join a plan at certain times during the year. See page 58. In most cases, you are enrolled in a plan for a year. ■■If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan. ■■If the plan decides to stop participating in Medicare, you will have to join another Medicare health plan or return to Original Medicare. See page 59.
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Section 2—Your Medicare Choices Medicare Advantage Plans
More About Medicare Advantage Plans (continued)
Blue words in the text are defined on pages 115–118.
■■You usually get prescription drug coverage (Part D) through the plan. If you are in a Medicare Advantage Plan that includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare. ■■You don’t need to buy (and can’t be sold) a Medigap (Medicare Supplement Insurance) policy while you are in a Medicare Advantage Plan. It won’t cover your Medicare Advantage Plan deductibles, copayment, or coinsurance.
Who Can Join? You can generally join a Medicare Advantage Plan if you meet these conditions: ■■You have Part A and Part B. ■■You live in the service area of the plan. ■■You don’t have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) except as explained on page 53. Note: In most cases, you can join a Medicare Advantage Plan only at certain times during the year. See page 58. If You Have Other Coverage Talk to your employer, union, or Indian or Tribal Health Program benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back. If You Have a Medigap (Medicare Supplement Insurance) Policy If you already have a Medigap policy, you can’t use it to pay for any expenses you have under a Medicare Advantage Plan. If you drop your Medigap policy to join a Medicare Advantage Plan, in most cases, you won’t be able to get it back. See pages 74–75.
Section 2—Your Medicare Choices Medicare Advantage Plans If You Have End-Stage Renal Disease (ESRD) If you have End-Stage Renal Disease (ESRD) and Original Medicare, you may join a Medicare Prescription Drug Plan. However, you usually can’t join a Medicare Advantage Plan. ■■If you are already in a Medicare Advantage Plan when you develop ESRD, you can stay in your plan or join another plan offered by the same company under certain circumstances. ■■If you have an employer or union health plan or other health coverage through a company that offers Medicare Advantage Plans, you may be able to join one of their Medicare Advantage Plans. ■■If you’ve had a successful kidney transplant, you may be able to join a Medicare Advantage Plan. If you have ESRD and are in a Medicare Advantage Plan, and the plan leaves Medicare or no longer provides coverage in your area, you have a one-time right to join another Medicare Advantage Plan. You don’t have to use your one-time right to join a new plan immediately. If you go directly to Original Medicare after your plan leaves or stops providing coverage, you will still have a one-time right to join a Medicare Advantage Plan later. You may also be able to join a Medicare Special Needs Plan (SNP) for people with ESRD if one is available in your area. For questions or complaints about kidney dialysis services, call your local ESRD Network Organization. An ESRD Network Organization is a group of kidney care experts paid by the Federal government to check and improve the care given to Medicare patients who get dialysis treatments for kidney care. Call 1-800-MEDICARE (1‑800‑633‑4227) to get the telephone number. TTY users should call 1-877-486-2048. For more information about ESRD, visit www.medicare.gov/Publications/Pubs/pdf/10128.pdf to view the booklet, “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”
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Section 2—Your Medicare Choices Medicare Advantage Plans
What You Pay Your out-of-pocket costs in a Medicare Advantage Plan depend on the following: ■■Whether the plan charges a monthly premium in addition to your Part B premium. ■■Whether the plan pays any of the monthly Part B premium. Some plans offer this option, usually for an extra cost. ■■Whether the plan has a yearly deductible or any additional deductibles. ■■How much you pay for each visit or service (copayments). ■■The type of health care services you need and how often you get them. ■■Whether you follow the plan’s rules, like using network providers. ■■Whether you need extra coverage and what the plan charges for it. ■■Whether the plan has a yearly limit on your out-of-pocket costs for all medical services.
Blue words in the text are defined on pages 115–118.
To learn more about your costs in specific Medicare Advantage Plans, contact the plans you are interested in to get more details. Visit www.medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227) to find plans in your area. TTY users should call 1‑877‑486‑2048. If you have limited income and resources, you may qualify for the following: ■■ Extra Help paying your Part D premium and other prescription drug coverage costs. See pages 78–81. ■■Help from your state to pay your Part B premium. See page 83.
Section 2—Your Medicare Choices Medicare Advantage Plans
How Do Medicare Advantage Plans Work? (Chart continues on next page.)
Health Maintenance Organization (HMO) Plan
Preferred Provider Organization (PPO) Plan
Can I get my health care from any doctor or hospital?
No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out‑of‑area dialysis). In some plans, you may be able to go out‑of‑network for certain services usually for a higher cost.
Yes. PPOs have network doctors and hospitals, but you can also use out‑of‑network providers for covered services, usually for a higher cost.
Are prescription drugs covered?
In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage.
In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers prescription drug coverage.
Do I need to choose a primary care doctor?
In most cases, yes.
No.
Do I have to get a referral to see a specialist?
In most cases, yes. Yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year) don’t require a referral.
No.
What else do I need to know about this type of plan?
■■ If your doctor leaves the plan, ■■ There are two types of PPOs— your plan will notify you. You can Regional PPOs and Local choose another doctor in the plan. PPOs. ■■ If you get health care outside the ■■ Regional PPOs serve one of 26 plan’s network, you may have to regions set by Medicare. pay the full cost. ■■ Local PPOs serve the counties ■■ It’s important that you follow the PPO Plan chooses to the plan’s rules, like getting prior include in its service area. approval for a certain service when needed.
Medicare Advantage Plans can vary. Read individual plan materials carefully to make sure you understand the plan’s rules. You may want to contact the plan to find out if the service you need is covered and how much it costs. Visit www.medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227) to find plans in your area. TTY users should call 1‑877‑486‑2048.
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Section 2—Your Medicare Choices Medicare Advantage Plans
How Do Medicare Advantage Plans Work? (continued) Private Fee-for-Service (PFFS) Plan
Medical Savings Account (MSA) Plan
Can I get my health care from any doctor or hospital?
In some cases, yes. You can Yes. Some plans may have preferred go to any Medicare-approved doctors and hospitals you could go to doctor or hospital that accepts for a lower cost. the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you will usually pay more to see out‑of‑network providers.
Are prescription drugs covered?
Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
No. You can join a Medicare Prescription Drug Plan to get drug coverage.
Do I need to choose a No. primary care doctor?
No.
Do I have to get a referral to see a specialist?
No.
No.
What else do I need to know about this type of plan?
■■ PFFS Plans aren’t the same ■■ Medicare MSA Plans have two parts: as Original Medicare or a high deductible health plan and Medigap. a bank account. Medicare gives the plan an amount each year for your ■■ The plan decides how much health care, and the plan deposits you must pay for services. a portion of this money into your ■■ Doctors, hospitals, and other account. The amount deposited is providers may decide on a less than your deductible amount, so case-by-case basis not to treat you will have to pay out-of-pocket you even if you’ve seen them before your coverage begins. before. ■■ For each service you get, check ■■ Money spent for Medicare-covered Part A and Part B services counts to make sure your doctors, toward your plan’s deductible. hospitals, and other providers will agree to treat you under the After you reach your out-of-pocket limit, your plan will cover your plan, and that they will accept Medicare-covered services in full. the PFFS Plan’s payment terms. ■■ Any money left in your account at ■■ In an emergency, doctors, the end of the year remains in your hospitals, and other providers account along with the deposit for must agree to treat you. next year.
Note: In 2010, Medicare MSA Plans are only available in Pennsylvania.
Section 2—Your Medicare Choices Medicare Advantage Plans
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How Do Medicare Advantage Plans Work? (continued) Special Needs Plan (SNP) Can I get my health care from any doctor or hospital?
You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). Plans typically have specialists for the diseases or conditions that affect their members.
Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage (Part D).
Do I need to choose a Generally, yes, or you may need to have a care coordinator to help plan primary care doctor? your care. Do I have to get a referral to see a specialist?
In most cases, yes. Yearly screening mammograms and an in‑network Pap test and pelvic exam (at least every other year) don’t require a referral.
What else do I need to know about this type of plan?
■■ A plan must limit plan membership to people in one of the following groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, a mental health condition, or HIV/AIDS). ■■ Plans may further limit membership within these groups. ■■ Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor’s orders. ■■ If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid. ■■ If you live in an institution, make sure that plan doctors or other health care providers serve people where you live.
Visit www.medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227) to find plans in your area. TTY users should call 1‑877‑486‑2048.
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Section 2—Your Medicare Choices Medicare Advantage Plans
When Can You Join, Switch, or Drop a Medicare Advantage Plan? You can join, switch, or drop a Medicare Advantage Plan at these times: ■■When you first become eligible for Medicare (the 7‑month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65). ■■If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability. You will have another chance to join 3 months before the month you turn age 65 to 3 months after the month you turn age 65. ■■Between November 15–December 31 each year. Your coverage will begin on January 1 of the following year, as long as the plan gets your enrollment request by December 31. ■■Between January 1–March 31 of each year. Your coverage will begin the first day of the month after the plan gets your enrollment form. During this period, you can’t do the following: ■■Join or switch to a plan with prescription drug coverage unless you already have Medicare prescription drug coverage (Part D). ■■Drop a plan with prescription drug coverage. ■■Join, switch, or drop a Medicare Medical Savings Account Plan. Blue words in the text are defined on pages 115–118.
In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan at other times. Some of these situations include the following: ■■If you move out of your plan’s service area ■■If you have both Medicare and Medicaid ■■If you qualify for Extra Help to pay for your prescription drug costs (see pages 78–81) ■■If you live in an institution (like a nursing home) You can call your State Health Insurance Assistance Program (SHIP) for more information. See pages 110–113 for the telephone number. No one should call you or come to your home uninvited to sell Medicare products. See pages 94–97 for more information about how to protect yourself from identity theft and fraud. If you believe a plan has misled you, call 1-800-MEDICARE (1‑800‑633‑4227).
Section 2—Your Medicare Choices Medicare Advantage Plans
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How Do You Join? If you choose to join a Medicare Advantage Plan, you may be able to join by completing a paper application, calling the plan, or enrolling on the plan’s Web site or on www.medicare.gov. You can also enroll by calling 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1-877-486-2048. Talk with the plan to find out how you can join. When you join a Medicare Advantage Plan, you will have to provide your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
How Do You Switch? If you are already in a Medicare Advantage Plan and want to switch, this is what you need to do: ■■To switch to a new Medicare Advantage Plan, simply join the plan you choose. You will be disenrolled automatically from your old plan when your new plan’s coverage begins. ■■To switch to Original Medicare, contact your current plan, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048. You will also need to decide about Medicare prescription drug coverage (Part D). Note: You can only switch plans at certain times. See page 58.
If Your Plan Decides Not to Participate in Medicare Your plan will send you a letter about your options. Generally, you will automatically return to Original Medicare if you don’t choose to join another Medicare Advantage Plan. You will also have the right to buy certain Medigap policies.
If Your Plan Stops Providing Service in Your Area You may be able to keep your coverage with that plan if there are no other Medicare Advantage Plans in your area. If your plan offers this option, you must agree to travel to the plan’s service area to get all your services (except for emergency and urgently‑needed care). If your plan doesn’t have this option, you will automatically return to Original Medicare. In this case you will have the right to buy a Medigap policy. If you decide to return to Original Medicare and you want drug coverage, you will need to join a Medicare Prescription Drug Plan.
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Section 2—Your Medicare Choices Other Medicare Health Plans
Other Medicare Health Plans Some types of Medicare health plans that provide health care coverage aren’t Medicare Advantage Plans but are still part of Medicare. Some of these plans provide Part A (Hospital Insurance) and/or Part B (Medical Insurance) coverage, and some also provide Part D (Medicare prescription drug coverage). These plans have some of the same rules as Medicare Advantage Plans. Some of these rules are explained briefly below and on the next page. However, each type of plan has special rules and exceptions, so you should contact any plans you’re interested in to get more details.
Blue words in the text are defined on pages 115–118.
Medicare Cost Plans Medicare Cost Plans are a type of Medicare health plan available in certain areas of the country. Here’s what you should know about Medicare Cost Plans: ■■You can join even if you only have Part B. ■■If you go to a non-network provider, the services are covered under Original Medicare. You would pay the Part B premium, and the Part A and Part B coinsurance and deductibles. ■■You can join anytime the plan is accepting new members. ■■You can leave anytime and return to Original Medicare. ■■You can either get your Medicare prescription drug coverage from the plan (if offered), or you can join a Medicare Prescription Drug Plan to add prescription drug coverage. There is another type of Medicare Cost Plan that only provides coverage for Part B services. These plans never include Part D. Part A services are covered through Original Medicare. These plans are either sponsored by employer or union group health plans or offered by companies that don’t provide Part A services. For more information about Medicare Cost Plans, contact the plans you’re interested in. You can also visit www.medicare.gov. Your State Health Insurance Assistance Program (SHIP) can also give you more information. See pages 110–113 for the telephone number.
Section 2—Your Medicare Choices Other Medicare Health Plans
Other Medicare Health Plans (continued) Demonstrations/Pilot Programs Demonstrations and pilot programs, sometimes called “research studies,” are special projects that test improvements in Medicare coverage, payment, and quality of care. They usually operate only for a limited time for a specific group of people and/or are offered only in specific areas. Check with the demonstration or pilot program for more information about how it works. For more information about current Medicare demonstrations and pilot programs, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227), and say “Agent.” TTY users should call 1‑877‑486‑2048. Programs of All-Inclusive Care for the Elderly (PACE) PACE combines medical, social, and long-term care services, and prescription drug coverage for frail elderly and disabled people. This program provides community-based care and services to people who otherwise need a nursing home-level of care. To qualify for PACE, you must meet the following conditions: ■■You are age 55 or older. ■■You live in the service area of a PACE organization. ■■You are certified by your state as meeting the need for a nursing home-level of care. ■■At the time you join, you are able to live safely in the community with the help of PACE services. PACE uses Medicare and Medicaid funds to cover all of your medically‑necessary care and services. You can have either Medicare or Medicaid or both to join PACE. Call your State Medical Assistance (Medicaid) office to find out if you are eligible and if there is a PACE site near you. For more information, you can also visit www.medicare.gov/Publications/Pubs/pdf/11341.pdf to view the fact sheet, “Quick Facts about Programs of All-inclusive Care for the Elderly (PACE).” See pages 100–102 for more information about PACE and long‑term care.
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
Medicare Prescription Drug Coverage (Part D) Medicare offers prescription drug coverage (Part D) to everyone with Medicare. To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.
Blue words in the text are defined on pages 115–118.
There are two ways to get Medicare prescription drug coverage: 1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. 2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” Both types of plans are called “Medicare drug plans” in this section.
Why Join a Medicare Drug Plan? Even if you don’t take a lot of prescription drugs now, you should still consider joining a Medicare drug plan. See page 44 for a list of things to consider when choosing a plan. If you decide not to join a Medicare drug plan when you are first eligible, and you don’t have other creditable prescription drug coverage (also called creditable coverage), you will likely pay a late enrollment penalty (higher premiums) if you join later. See page 67 for more information on creditable coverage and the late enrollment penalty. Note: Discount cards, doctor samples, free clinics, drug discount Web sites, and manufacturer’s pharmacy assistance programs aren’t considered prescription drug coverage and aren’t creditable coverage. If you have limited income and resources, you may qualify for Extra Help from Medicare to pay for prescription drug coverage. You may also be able to get help from your state. See pages 78–84.
Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
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Who Can Get Medicare Drug Coverage? To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B. If you would like to get prescription drug coverage through a Medicare Advantage Plan, you must have Part A and Part B. You must also live in the service area of the Medicare drug plan you want to join. If you have employer or union coverage, call your benefits administrator before you make any changes, or before you sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependants.
When Can You Join, Switch, or Drop a Medicare Drug Plan? You can join, switch, or drop a Medicare drug plan at these times: ■■When you are first eligible for Medicare (the 7‑month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65). ■■If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability. You will have another chance to join 3 months before the month you turn age 65 to 3 months after the month you turn age 65. ■■Between November 15–December 31 each year. Your coverage will begin on January 1 of the following year, as long as the plan gets your enrollment request by December 31. ■■Anytime, if you qualify for Extra Help or if you have both Medicare and Medicaid. In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop Medicare drug plans during a special enrollment period (like if you move out of the service area, lose other creditable prescription drug coverage, or live in an institution).
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
When Can You Join, Switch, or Drop a Medicare Drug Plan? (continued) Call your State Health Insurance Assistance Program (SHIP) for more information. See pages 110–113 for the telephone number. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048.
How Do You Join?
Blue words in the text are defined on pages 115–118.
Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, or enrolling on the plan’s Web site or on www.medicare.gov. You can also enroll by calling 1-800-MEDICARE. Medicare drug plans aren’t allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this. Contact the plan to find out how you can join. When you join a Medicare drug plan, you will have to provide your Medicare number and the date your Part A or Part B coverage started. This information is on your Medicare card. Visit www.medicare.gov, or call 1‑800‑MEDICARE for a list of the Medicare plans in your area.
How Do You Switch? Depending on your circumstances, you can switch to a new Medicare drug plan simply by joining another drug plan during one of the times listed on page 63. You don’t need to cancel your old Medicare drug plan or send them anything. Your old Medicare drug plan coverage will end when your new drug plan begins. You should get a letter from your new Medicare drug plan telling you when your coverage begins. After you join a Medicare drug plan, the plan will mail you membership materials, including a card to use when you get your prescriptions filled. Note: If your Medicare Prescription Drug Plan decides not to participate in Medicare or stops providing service in your area, your plan will send you a letter about your options. You will have the opportunity to join a different Medicare Prescription Drug Plan. If you have a Medicare Advantage Plan with prescription drug coverage, see page 59 for more information.
Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
What You Pay Exact coverage and costs are different for each Medicare drug plan, but all plans must provide at least a standard level of coverage set by Medicare. Below and continued on the next page are descriptions of the payments you make throughout the year in a Medicare drug plan. After the descriptions is an example of what someone may pay in a Medicare drug plan. Your actual drug plan costs will vary depending on the prescriptions you use, the plan you choose, whether you go to a pharmacy in your plan’s network, whether your drugs are on your plan’s formulary, and whether you qualify for Extra Help paying your Part D costs. ■■Monthly premium—Most drug plans charge a monthly fee that varies by plan. You pay this in addition to the Part B premium. If you belong to a Medicare Advantage Plan (like an HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug coverage. ■■Yearly deductible—Amount you pay for your prescriptions before your plan begins to pay. Some drug plans don’t have a deductible. ■■Copayments or coinsurance—Amounts you pay at the pharmacy for your covered prescriptions after the deductible. You pay your share, and your drug plan pays its share for covered drugs. ■■Coverage gap—Most Medicare drug plans have a coverage gap. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs outof-pocket for your prescriptions up to a yearly limit. Your yearly deductible, your coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium or what you pay for drugs that aren’t on your plan’s formulary. There are plans that offer some coverage during the gap, like for generic drugs. However, plans with gap coverage may charge a higher monthly premium. Check with the drug plan first to see if your drugs would be covered during the gap. For help comparing plan costs, contact your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number. You can also visit www.medicare.gov and select “Compare Medicare Prescription Drug Plans.”
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
What You Pay (continued) Catastrophic coverage—Once you reach your plan’s out-of-pocket limit during the coverage gap, you automatically get “catastrophic coverage.” Catastrophic coverage assures that once you have spent up to your plan’s out-of-pocket limit for covered drugs, you only pay a small coinsurance amount or copayment for the drug for the rest of the year. Note: If you get Extra Help paying your drug costs, you won’t have a coverage gap and will pay only a small or no copayment once you reach catastrophic coverage. See pages 78–81. The example below shows costs for covered drugs in 2010 for a plan that has a coverage gap. Ms. Smith joins the ABC Prescription Drug Plan. Her coverage begins on January 1, 2010. She doesn’t get Extra Help and uses her Medicare drug plan membership card when she buys prescriptions. Monthly Premium—Ms. Smith pays a monthly premium throughout the year. 1. Yearly Deductible
2. Copayment or Coinsurance
3. Coverage Gap
4. Catastrophic Coverage
Ms. Smith pays the first $310 of her drug costs before her plan starts to pay its share.
Ms. Smith pays a copayment, and her plan pays its share for each covered drug until what they both pay (plus the deductible) reaches $2,830.
Once Ms. Smith and her plan have spent $2,830 for covered drugs, she is in the coverage gap. She will have to pay all of her drug costs until she has spent $4,550.
Once Ms. Smith has spent $4,550 out‑of‑pocket for the year, her coverage gap ends. Now she only pays a small copayment for each drug until the end of the year.
Call the plans you’re interested in to get specific Medicare drug plan costs. You can also visit www.medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.
Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
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What is the Part D Late Enrollment Penalty?
Blue words in the text are defined on pages 115–118.
The late enrollment penalty is an amount that is added to your Part D premium. You may owe a late enrollment penalty if one of the following is true: ■■You didn’t join a Medicare drug plan when you were first eligible for Medicare, and you didn’t have other creditable prescription drug coverage. ■■You had a break in your Medicare prescription drug coverage or other creditable coverage of at least 63 days in a row. Note: If you get Extra Help, you don’t pay a late enrollment penalty. Here are a few ways to avoid paying a penalty: ■■Join a Medicare drug plan when you’re first eligible. You won’t have to pay a penalty, even if you’ve never had prescription drug coverage before. ■■Don’t go for more than 63 days in a row without a Medicare drug plan or other creditable coverage. Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, or the Department of Veterans Affairs. Your plan will tell you each year if your drug coverage is creditable coverage. Keep this information, because you may need it if you join a Medicare drug plan later. ■■Don’t go 63 days or more in a row without letting your Medicare drug plan know if you had other creditable coverage. When you join a plan, you may get a letter asking if you have creditable coverage. Complete the form they send you. If you don’t tell the plan about your creditable coverage, you may have to pay a penalty.
How Much More Will You Pay? When you join a Medicare drug plan, the plan will tell you if you owe a penalty, and what your premium will be. To estimate your penalty amount, count the number of full months that you didn’t have creditable coverage after you were eligible to join a Medicare drug plan. If you multiply this number by the “1% penalty calculation” which is $.32 in 2010, you can estimate the amount that will be added each month to your Medicare drug plan’s premium for the current year. This penalty amount may increase every year.
If You Don’t Agree With Your Penalty If you don’t agree with your late enrollment penalty, you may be able to ask Medicare for a review or reconsideration. You will need to fill out a reconsideration request form (that your drug plan will send you), and you will have the chance to provide proof that supports your case such as information about previous prescription drug coverage.
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
Important Drug Coverage Rules The following information can help answer common questions as you begin to use your coverage. To Fill a Prescription Before You Get Your Membership Card Within 2 weeks after your plan gets your completed application, you will get a letter from the plan letting you know they got your information. You should get a welcome package with your membership card within 5 weeks or sooner. If you need to go to the pharmacy before your membership card arrives, you can use any of the following as proof of membership in your Medicare drug plan: ■■A letter from the plan ■■An enrollment confirmation number that you got from the plan, the plan name, and telephone number You should also bring your Medicare and/or Medicaid card, proof of any other prescription drug coverage, and a photo ID. If you qualify for Extra Help, see page 81 for more information about what you can use as proof of Extra Help. If you don’t have any of the items listed above, and your pharmacist can’t get your drug plan information any other way, you may have to pay out-of-pocket for your prescriptions. If you do, save the receipts and contact your plan to get money back. If you want to know how Medicare prescription drug coverage works with other drug coverage you may have, see pages 71–72. Once you consider your options and choose a plan, join early to give the plan time to mail your membership card, acknowledgement letter, and welcome package before your coverage becomes effective. This way, even if you go to the pharmacy on your first day of coverage, you can get your prescriptions filled without delay. If you don’t get these items, call your plan.
Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
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Important Drug Coverage Rules (continued)
Blue words in the text are defined on pages 115–118.
Plans may have the following coverage rules: ■■Prior authorization—You and/or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it. ■■Quantity limits—Limits on how much medication you can get at a time. ■■Step therapy—You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug. If your prescriber believes that one of these coverage rules should be waived, you can ask for an exception. See pages 90–91. What Are “Tiers”? Many Medicare drug plans place drugs into different “tiers.” Drugs in each tier have a different cost. For example, a drug in a lower tier will cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment. Note: Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness except for vaccines covered under Part B. Information about a plan’s list of covered drugs (called a formulary) isn’t included in this handbook because each plan has its own formulary. Formularies can change. Contact the plan for its current formulary, or visit the plan’s Web site. You can also visit www.medicare.gov and select “Compare Medicare Prescription Drug Plans.” In most cases the prescription drugs you get in an outpatient setting like an emergency department (sometimes called “self‑administered drugs”) aren’t covered by Part B. Your Medicare drug plan may cover these drugs under certain circumstances. You will likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your plan for more information. You can also visit www.medicare.gov/Publications/Pubs/pdf/11333.pdf to view the fact sheet, “How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings.”
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
Important Drug Coverage Rules (continued) Ways to Pay Your Premium You have choices in the way you pay your Medicare drug plan premium. Depending on your plan and your situation, you may be able to pay your Medicare drug plan premium in one of four ways: 1. Deducted from your checking or savings account. 2. Charged to a credit or debit card. 3. Billed to you each month directly by the plan. Some plans bill in advance for coverage the next month. Send your payment to the plan (not Medicare). Contact your plan for the payment address. 4. Deducted from your monthly Social Security payment. Contact your drug plan (not Social Security) to ask for this payment option. With this option, your first deductions usually take 3 months to start, and 3 months of premiums will likely be collected at one time. You may also see a delay in premiums being withheld if you switch or leave plans. For more information about your Medicare drug plan premium or ways to pay for it, contact your drug plan. Use the following resources to get more information about Medicare prescription drug coverage: ■■Contact the plans you are interested in. ■■Visit www.medicare.gov/pdphome.asp to get general information, view publications, and compare plans in your area. ■■Call 1-800-MEDICARE (1-800-633-4227), and say “Drug Coverage.” TTY users should call 1-877-486-2048. ■■Contact your State Health Insurance Assistance Program (SHIP) for free, personalized health insurance counseling. See pages 110–113 for the telephone number.
Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
Other Private Insurance The charts on the next two pages provide information about how other insurance you have works with, or is affected by, Medicare prescription drug coverage (Part D). Employer or Union Health Coverage—Health coverage from your, your spouse’s, or other family member’s current or former employer or union. If you have prescription drug coverage based on your current or previous employment, your employer or union will notify you each year to let you know if your drug coverage is creditable. Keep the information you get. Call your benefits administrator for more information before making any changes to your coverage. COBRA—A Federal law that may allow you to temporarily keep employer or union health coverage after the employment ends or after you lose coverage as a dependent of the covered employee. As explained on page 24, there may be reasons why you should take Part B instead of COBRA. However, if you take COBRA and it includes creditable prescription drug coverage, you will have a special enrollment period to join a Medicare drug plan without paying a penalty when the COBRA coverage ends. Talk with your State Health Insurance Assistance Program (SHIP) to see if COBRA is a good choice for you. See pages 110–113 for the telephone number. Medigap (Medicare Supplement Insurance) Policy with Prescription Drug Coverage—Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. However, it may be to your advantage to join a Medicare drug plan because most Medigap drug coverage isn’t creditable. If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information. Note: Keep any creditable coverage information you get from your plan. You may need it if you decide to join a Medicare drug plan later. Don’t send creditable coverage letters/certificates to Medicare.
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Section 2—Your Medicare Choices Medicare Prescription Drug Coverage
Other Government Insurance Federal Employee Health Benefits Program (FEHBP)—Health coverage for current and retired Federal employees and covered family members. If you join a Medicare drug plan, you can keep your FEHBP plan, and your plan will let you know who pays first. For more information, contact the Office of Personnel Management at 1-888-767-6738, or visit www.opm.gov/insure. TTY users should call 1-800-878-5707. You can also call your plan if you have questions. Veterans’ Benefits—Health coverage for veterans and people who have served in the U.S. military. You may be able to get prescription drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you can’t use both types of coverage for the same prescription. For more information, call the VA at 1-800-827-1000, or visit www.va.gov. TTY users should call 1-800-829-4833. TRICARE (Military Health Benefits)—Health care plan for active-duty service members, retirees, and their families. Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you aren’t required to join a Medicare Prescription Drug Plan. If you do, your Medicare drug plan pays first, and TRICARE pays second. If you join a Medicare Advantage Plan with prescription drug coverage, TRICARE won’t pay for your prescription drugs. For more information, call the TRICARE Pharmacy Program at 1‑877‑363‑1303, or visit www.tricare.mil. TTY users should call 1-877-540-6261. Indian Health Services—Health care for people who are American Indian/ Alaska Native through an Indian health care provider. If you get prescription drugs through an Indian health pharmacy, you pay nothing and your coverage won’t be interrupted. Joining a Medicare drug plan may help your Indian health provider with costs, because the drug plan pays part of the cost of your prescriptions. Talk to your benefits coordinator who can help you choose a plan that meets your needs and tell you how Medicare works with your health care system. Note: The types of insurance listed on this page are all considered creditable prescription drug coverage. If you have one of these types of insurance, in most cases, it will be to your advantage to keep your current coverage.
Section 2—Your Medicare Choices Who Pays First
Who Pays First When You Have Other Insurance?
When you have other insurance (like employer group health coverage), there are rules that decide whether Medicare or your other insurance pays first. The insurance that pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. If your other coverage is from an employer or union group health plan, these rules apply: ■■If you are retired, Medicare pays first. ■■If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the size of the employer, and whether you have Medicare based on age, disability, or End‑Stage Renal Disease (ESRD): — If you are under age 65 and disabled, your plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees. — If you are over age 65 and still working, your plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees. ■■If you have Medicare because you have ESRD, your plan pays first for the first 30 months you have Medicare. The following types of coverage usually pay first: ■■No-fault insurance (including automobile insurance) ■■Liability (including automobile insurance) ■■Black lung benefits ■■Workers’ compensation Medicaid and TRICARE never pay first. They only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Medicare’s Coordination of Benefits Contractor at 1‑800-999-1118. TTY users should call 1‑800‑318‑8782. You may need to give your Medicare number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.
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Section 2—Your Medicare Choices Medigap
Medigap (Medicare Supplement Insurance) Policies
Blue words in the text are defined on pages 115–118.
Original Medicare pays for many, but not all, health care services and supplies. A Medigap policy, sold by private insurance companies, can help pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, both plans will pay their share of Medicare‑approved amounts for covered health care costs. Medicare doesn’t pay any of the costs for a Medigap policy. Every Medigap policy must follow Federal and state laws designed to protect you, and it must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies can sell you only a “standardized” Medigap policy identified in most states by letters, Plans A through N. All plans offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs. Note: In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. NEW: Starting June 1, 2010, the types of Medigap Plans that you can buy will change: 1. There will be two new Medigap Plans offered—Plans M and N. 2. Plans E, H, I, and J will no longer be available to buy. If you already have or you buy Plan E, H, I, or J before June 1, 2010, you can keep that plan. Contact your plan for more information. Insurance companies may charge different premiums for exactly the same Medigap coverage. As you shop for a Medigap policy, be sure you are comparing the same Medigap policy (for example, compare Plan A from one company with Plan A from another company). In some states, you may be able to buy another type of Medigap policy called Medicare SELECT (a Medigap policy that requires you to use specific hospitals and, in some cases, specific doctors to get full coverage).
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If You Want to Buy a Medigap Policy ■■Generally, you must have Part A and Part B to buy a Medigap policy. ■■You pay a monthly premium for your Medigap policy to the private insurer, and you pay your monthly Part B premium. See page 119. ■■A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you must each buy separate policies. ■■It’s important to compare Medigap policies since the costs can vary and may go up as you get older. Some states limit Medigap costs. ■■The best time to buy a Medigap policy is during the 6-month period that begins on the first day of the month in which you are both age 65 or older and enrolled in Part B. (Some states have additional open enrollment periods.) After this initial enrollment period, your option to buy a Medigap policy may be limited. ■■If you are under age 65, you may have additional rights to buy a Medigap policy, depending on the laws in your state. ■■If you have a Medigap policy and join a Medicare Advantage Plan (like an HMO or PPO), you may want to consider dropping your Medigap policy. You can continue to pay your Medigap premium, but your policy can’t be used to pay your Medicare Advantage Plan copayments and deductibles. ■■If you want to drop your Medigap policy, you must contact your insurance company to cancel the policy. ■■If you already have a Medicare Advantage Plan, it’s illegal for anyone to sell you a Medigap policy unless you are switching back to Original Medicare. ■■If you join a Medicare health plan for the first time, and you aren’t happy with the plan, you will have special rights to buy a Medigap policy if you return to Original Medicare within 12 months of joining. — If you had a Medigap policy before you joined, you may be able to get the same plan back if the company still sells it. — The Medigap policy can no longer have prescription drug coverage even if you had it before, but you may be able to join a Medicare Prescription Drug Plan. — If you joined a Medicare health plan when you were first eligible for Medicare, you can choose from any policy. ■■If you buy a Medicare SELECT policy you also have rights to change your mind within 12 months and switch to a standard Medigap policy. ■■You can’t have drug coverage in both your Medigap policy and a Medicare drug plan. See page 71.
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Section 2—Your Medicare Choices Medigap For more information about Medigap policies ■■Visit www.medicare.gov/Publications/Pubs/pdf/02110.pdf to view the booklet, “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.” ■■Call your State Insurance Department to get more information. Call 1-800-MEDICARE (1-800-633-4227) to get the telephone number. TTY users should call 1-877-486-2048.
Blue words in the text are defined on pages 115–118.
To find and compare Medigap policies ■■Visit www.medicare.gov, and select “Compare Medicare Health Plans and Medigap Policies in Your Area.” ■■Call 1-800-MEDICARE. ■■Call your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number.
SECTION
3
Programs for People with Limited Income and Resources
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here are Federal and state programs available for people with limited income and resources. These programs may help you save on your health care and prescription drug costs or provide extra income. Section 3 includes information about the following: Extra Help Paying for Medicare Prescription Drug Coverage (Part D) . . . . . . . . . . . . . . . . . . 78–81 Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 State Pharmacy Assistance Programs (SPAPs) . . . . . . . . . . 82 Programs of All-inclusive Care for the Elderly (PACE) . . . . . 82 Medicare Savings Programs . . . . . . . . . . . . . . . . . . . . 83 Supplemental Security Income (SSI) Benefits . . . . . . . . . . 84 Programs for People Who Live in the U.S. Territories . . . . . Keep all information you get from Medicare, Social Security, your Medicare health or prescription drug plan, Medigap insurer, or employer or union. This may include notices of award or denial, Annual Notices of Change, notices of creditable prescription drug coverage, or Medicare Summary Notices. You may need these documents to apply for the programs explained in this section. Also keep copies of any applications you submit.
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Section 3—Programs for People with Limited Income and Resources
Programs for People with Limited Income and Resources If you have limited income and resources, you might qualify for help to pay for some health care and prescription drug costs. The U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of Puerto Rico, and the Commonwealth of Northern Mariana Islands provide their residents help with Medicare drug costs. This help isn’t the same as the Extra Help described below. See page 84 for more information.
Extra Help Paying for Medicare Prescription Drug Coverage (Part D) You may qualify for Extra Help, also called the low-income subsidy (LIS) from Medicare to pay prescription drug costs if your yearly income and resources are below the following limits in 2009: ■■Single person—Income less than $16,245 and resources less than $12,510 ■■Married person living with a spouse and no other dependents—Income less than $21,855 and resources less than $25,010 These amounts may change in 2010. You may qualify even if you have a higher income (like if you still work, or if you live in Alaska or Hawaii, or have dependents living with you). Resources include money in a checking or savings account, stocks, and bonds. Resources don’t include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person), or life insurance policies.
Blue words in the text are defined on pages 115–118.
If you qualify for Extra Help and join a Medicare drug plan, you will get the following: ■■Help paying your Medicare drug plan’s monthly premium. Depending on your income and resources and your drug plan’s premium, you may pay a reduced premium or no premium for a basic plan. For an enhanced drug plan (a plan that may cover more drugs and generally has a higher monthly premium), you must pay more for the extra coverage. ■■Help paying any yearly deductible. ■■Help paying coinsurance and copayments for prescription drugs that are on your plan’s formulary (list of covered drugs). You generally pay all costs for drugs that aren’t on your plan’s formulary unless you are granted an exception. See page 90. ■■No coverage gap. ■■No late enrollment penalty.
Section 3—Programs for People with Limited Income and Resources
Extra Help Paying for Medicare Prescription Drug Coverage (Part D) (continued) You automatically qualify for Extra Help if you have Medicare and meet one of these conditions: ■■You have full Medicaid coverage. ■■You get help from your state Medicaid program paying your Part B premiums (belong to a Medicare Savings Program). ■■You get Supplemental Security Income (SSI) benefits. Medicare will mail you a purple letter to let you know you automatically qualify for Extra Help. You don’t need to apply for Extra Help if you get this letter. ■■Keep the letter for your records. ■■If you aren’t already in a plan, you must join a Medicare drug plan to get this Extra Help. ■■If you don’t join a drug plan, Medicare may enroll you in one. If Medicare enrolls you in a plan, Medicare will send you a yellow or green letter letting you know when your coverage begins. ■■Different plans cover different drugs. Check to see if the plan you are enrolled in covers the drugs you use and if you can go to the pharmacies you want. Compare with other plans in your area. ■■If you’re getting Extra Help, you can switch to another Medicare drug plan anytime. Your coverage will be effective the first day of the next month. ■■In most cases, you will pay only a small amount for each covered prescription. ■■If you have Medicaid, Medicare will provide you with prescription drug coverage instead of Medicaid. Medicaid may still cover some drugs that Medicare prescription drug coverage doesn’t cover. Medicaid may still cover other care that Medicare doesn’t cover. ■■If you have Medicaid and live in certain institutions (like a nursing home), you pay nothing for your covered prescription drugs. If you qualify, your drug costs in 2010 will be no more than $2.50 for each generic drug and $6.30 for each brand‑name drug. Look on the Extra Help letters you get, or contact your plan to find out your exact costs.
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Section 3—Programs for People with Limited Income and Resources
Extra Help Paying for Medicare Prescription Drug Coverage (Part D) (continued) If you don’t want to join a Medicare drug plan (for example, because you want to keep your employer or union coverage instead), call 1-800-MEDICARE (1-800-633-4227) or the plan listed in your letter. TTY users should call 1-877-486-2048. Tell them you don’t want to be in a Medicare drug plan (you want to “opt out”). If you continue to qualify for Extra Help, you won’t have to pay a penalty if you join later. See page 67.
Blue words in the text are defined on pages 115–118.
If you didn’t automatically qualify for Extra Help, you can apply: ■■Call Social Security at 1-800-772-1213 to apply by phone or to get a paper application. TTY users should call 1-800-325-0778. ■■Visit www.socialsecurity.gov to apply online. ■■Apply at your State Medical Assistance (Medicaid) office. Call 1-800-MEDICARE, and say “Medicaid” to get the telephone number, or visit www.medicare.gov. Note: You can apply for Extra Help at any time. To get answers to your questions about Extra Help, call your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number. You can also call 1-800-MEDICARE. If you apply and qualify for Extra Help, you must join a Medicare drug plan to get this help. If you don’t join a drug plan, Medicare may enroll you in one. If Medicare enrolls you in a plan, Medicare will send you a green letter letting you know when your coverage begins. Check to see if the plan you are enrolled in covers the drugs you use and if you can go to the pharmacies you want. If not, you can switch plans at anytime. If you have employer or union coverage and you join a Medicare drug plan, you may lose your employer or union coverage even if you qualify for Extra Help. Call your employer’s benefits administrator for more information before you join. Medicare gets data from your state or Social Security that tells whether you qualify for Extra Help. If Medicare doesn’t have the right information, you may be paying the wrong amount for your prescription drug coverage.
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Extra Help Paying for Medicare Prescription Drug Coverage (Part D) (continued) Paying the Right Amount If you automatically qualify, you can show your drug plan the purple letter and the yellow or green letter you got from Medicare as proof that you qualify. If you applied for Extra Help, you can show your “Notice of Award” from Social Security as proof that you qualify. You can also give your plan any of the following documents (also called “Best Available Evidence”) as proof that you qualify for Extra Help. Your plan must accept these documents. Each item listed below must show that you were eligible for Medicaid during a month after June of 2009. Other Proof You Have Medicaid ■■A copy of your Medicaid card ■■A copy of a state document that shows you have Medicaid ■■A print-out from a state electronic enrollment file or screen print from your state’s Medicaid systems that shows you have Medicaid ■■Any other document from your state that shows you have Medicaid
Proof You Have Medicaid and Live in an Institution ■■A bill from the institution (like a nursing home) or a copy of a state document showing Medicaid payment to the institution for at least a month ■■A screen print from your state’s Medicaid systems showing that you lived in the institution for at least a month
Call your drug plan to find out how you can provide them with this information. If you think you qualify for Extra Help because you have Medicaid, but you don’t have proof, ask your drug plan for help. They must help you. If you paid for prescriptions since you qualified for Extra Help, your plan should pay you back some of these costs. Keep the receipts, and call your plan for more information. If your drug plan doesn’t correct a problem to help you pay the right amount, doesn’t respond to your request for help, or takes longer than expected to get back to you, call 1-800-MEDICARE (1‑800‑633‑4227) to file a complaint. TTY users should call 1-877-486-2048.
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Section 3—Programs for People with Limited Income and Resources
Medicaid
Blue words in the text are defined on pages 115–118.
Medicaid is a joint Federal and state program that helps pay medical costs if you have limited income and resources and meet other eligibility requirements. Some people qualify for both Medicare and Medicaid (these people are also called “dual‑eligibles”). ■■If you have Medicare and full Medicaid coverage, most of your health care costs are covered. You have the option of Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). ■■Medicaid programs vary from state to state. They may also be called by different names, such as “Medical Assistance” or “Medi-Cal.” ■■People with Medicaid may get coverage for services that Medicare doesn’t fully cover, such as nursing home and home health care. ■■Each state has different Medicaid eligibility income and resource limits and other eligibility requirements. ■■In some states, you may need to apply for Medicare to be eligible for Medicaid. ■■Call your State Medical Assistance (Medicaid) office for more information and to see if you qualify. Call 1-800-MEDICARE (1‑800‑633-4227) and say “Medicaid” to get the telephone number for your State Medical Assistance (Medicaid) office. TTY users should call 1‑877‑486-2048. You can also visit www.medicare.gov.
State Pharmacy Assistance Programs (SPAPs) Many states have State Pharmacy Assistance Programs (SPAPs) that help certain people pay for prescription drugs based on financial need, age, or medical condition. Each SPAP makes its own rules about how to provide drug coverage to its members. Depending on your state, the SPAP will help you in different ways. To find out about the SPAP in your state, call your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number.
Programs of All-Inclusive Care for the Elderly (PACE) PACE combines medical, social, and long-term care services, and prescription drug coverage for frail elderly and disabled people. This program allows people who need a nursing home-level of care to remain in the community. See page 101 for more information.
Section 3—Programs for People with Limited Income and Resources
Medicare Savings Programs (Help With Medicare Costs) States have programs that pay Medicare premiums and, in some cases, may also pay Part A and Part B deductibles and coinsurance. These programs help people with Medicare save money each year. To qualify for a Medicare Savings Program, you must meet all of these conditions: ■■Have Part A ■■Single person—Have monthly income less than $1,239 and resources less than $8,100 ■■Married and living together—Have monthly income less than $1,660 and resources less than $12,910 Note: These amounts may change each year. Many states figure your income and resources differently or may not have limits at all, so you may qualify in your state even if your income is higher. Resources include money in a checking or savings account, stocks, and bonds. Resources don’t include your home, car, burial plot, up to $1,500 for burial expenses (per person), furniture, or other household items. For More Information ■■Call or visit your State Medical Assistance (Medicaid) office, and ask for information on Medicare Savings Programs. The names of these programs and how they work may vary by state. Call if you think you qualify for any of these programs, even if you aren’t sure. ■■Call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid” to get the telephone number for your state. TTY users should call 1-877-486-2048. ■■Visit www.medicare.gov/Publications/Pubs/pdf/10126.pdf to view the brochure, “Get Help With Your Medicare Costs: Getting Started.” ■■Contact your State Health Insurance Assistance Program (SHIP) for free health insurance counseling. See pages 110–113 for the telephone number.
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Section 3—Programs for People with Limited Income and Resources
Supplemental Security Income (SSI) Benefits SSI is a monthly amount paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits provide cash to meet basic needs for food, clothing, and shelter. SSI benefits aren’t the same as Social Security benefits.
Blue words in the text are defined on pages 115–118.
To get SSI benefits, you must also meet these conditions: ■■Be a resident of the U.S. (includes the Northern Mariana Islands, but not the territories listed below). ■■Not be out of the country for a full calendar month or more than 30 consecutive days. ■■Be either a U.S. citizen or national, or in one of certain categories of eligible non–citizens. People who live in Puerto Rico, the Virgin Islands, Guam, or American Samoa generally can’t get SSI. You can visit www.socialsecurity.gov, and use the “Benefit Eligibility Screening Tool” to find out if you may be eligible for SSI or other benefits. Call Social Security at 1-800-772-1213, or contact your local Social Security office for more information. TTY users should call 1‑800‑325‑0778.
Programs for People Who Live in the U.S. Territories There are programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa to help people with limited income and resources pay their Medicare costs. Programs vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about their rules, or call 1-800-MEDICARE (1‑800‑633‑4227) and say “Medicaid” for more information. TTY users should call 1‑877‑486‑2048. You can also visit www.medicare.gov.
Children’s Health Insurance Program Do you have children or grandchildren who need health insurance? A new bill signed into law in 2009 extends health insurance coverage to millions of uninsured children. Each state has its own program, with its own eligibility rules. In many states, uninsured children 18 years old and younger, whose families earn up to $44,500 a year (for a family of four) are eligible for free or low-cost health insurance that pays for doctor visits, dental care, prescription drugs, hospitalizations, and much more. Call 1-877-KIDS-NOW (1-877-543-7669), or visit www.insurekidsnow.gov for more information about the Children’s Health Insurance Program.
SECTION
4
Protecting Yourself and Medicare
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ou can protect yourself and Medicare by understanding your rights (including your right to appeal) and knowing how to identify and report fraud. Section 4 includes information about the following: Medicare Rights and Appeals Information . . . . . . . . . . 86–88 Advance Beneficiary Notices (ABNs) . . . . . . . . . . . . . . . 89 Appeals (Medicare Drug Plans) . . . . . . . . . . . . . . . . 90–91 How Medicare Uses Your Personal Information . . . . . . 92–93 Protecting Yourself From Fraud and Identity Theft . . . . . 94–95 Senior Medicare Patrol (SMP) . . . . . . . . . . . . . . . . . . . 95 Billing Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . 96–97 How Medicare Protects You . . . . . . . . . . . . . . . . . . . . 97 Medicare’s Beneficiary Ombudsman . . . . . . . . . . . . . . . 98
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Section 4—Protecting Yourself and Medicare
Your Medicare Rights No matter what type of Medicare coverage you have, you have certain guaranteed rights. As a person with Medicare, you have the right to all of the following: ■■Be treated with dignity and respect at all times ■■Be protected from discrimination ■■Have access to doctors, specialists, and hospitals ■■Have your questions about Medicare answered ■■Learn about all of your treatment choices and participate in treatment decisions ■■Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors ■■Get emergency care when and where you need it ■■Get a decision about health care payment or services, or prescription drug coverage ■■Get a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage ■■File complaints (sometimes called grievances), including complaints about the quality of your care ■■Have your personal and health information kept private
What Is an Appeal? An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan. You can appeal if Medicare or your plan denies one of the following: ■■A request for a health care service, supply, or prescription that you think you should be able to get ■■A request for payment for health care services or supplies or a prescription drug you already got that was denied ■■A request to change the amount you must pay for a prescription drug You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need. If you decide to file an appeal, ask your doctor or other health care provider or supplier for any information that may help your case.
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How to File an Appeal How you file an appeal depends on the type of Medicare coverage you have: ■■If you have a Medicare health plan, look at your plan materials, call your plan, or visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet, “Your Medicare Rights and Protections.” ■■If you have a Medicare Prescription Drug Plan, look at your plan materials, call your plan, or look on pages 90–91 to learn how to file an appeal. ■■If you have Original Medicare, do the following to file an appeal: 1. Get the Medicare Summary Notice (MSN) that shows the item or service you are appealing. Your MSN is the statement you get every 3 months that lists all the services billed to Medicare and tells you if Medicare paid for the services. See page 46. 2. Circle the item(s) you disagree with on the MSN, and write an explanation on the MSN of why you disagree. 3. Sign, write your telephone number, and provide your Medicare number on the MSN. Keep a copy for your records. 4. Send the MSN, or a copy, to the Medicare contractor’s address listed on the MSN. You can also send any additional information you may have about your appeal. 5. You must file the appeal within 120 days of the date you get the MSN. If you want to file an appeal, make sure you read your MSN carefully, and follow the instructions. You can also use CMS Form 20027, and file it with the Medicare contractor at the address listed on the MSN. To view or print this form, visit www.cms.hhs.gov/cmsforms/downloads/CMS20027.pdf. You can also file a fast appeal in some cases. See page 88.
Blue words in the text are defined on pages 115–118.
Find Out if Medicare or Your Plan Was Billed For the Services You Got Check with your health care provider or supplier to see if they submitted the bill to Medicare or your plan. Do the following to find out what was billed: ■■Ask your health care provider or supplier for an itemized statement. They should give this to you within 30 days. ■■Check your MSN if you have Original Medicare to see if the service was billed to Medicare. If you are in a Medicare plan, check with your plan. ■■Visit www.MyMedicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to view your Medicare claims. TTY users should call 1-877-486-2048.
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Section 4—Protecting Yourself and Medicare
Your Right to a Fast Appeal
Blue words in the text are defined on pages 115–118.
If you are getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicarecovered services are ending too soon, you have the right to a fast appeal (also called an “expedited review” or an “immediate appeal”). Your provider will give you a notice at least 2 days before your services end that will tell you how to ask for a fast appeal. If you don’t get this notice, ask your provider for it. With a fast appeal, an independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue. ■■You may ask your doctor for any information that may help your case if you decide to file a fast appeal. ■■You must call your local QIO to request a fast appeal no later than noon on the day before your notice says your coverage will end. ■■The number for the QIO in your state should be on your notice. You can also call 1‑800‑MEDICARE (1-800-633-4227) to get the telephone number, or visit www.medicare.gov. TTY users should call 1‑877‑486‑2048. ■■If you miss the deadline, you still have appeal rights: — If you have Original Medicare, call your local QIO. — If you are in a Medicare health plan, call your plan. Look in your plan materials to get the telephone number. Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal. See pages 110–113 for the telephone number.
Section 4—Protecting Yourself and Medicare
Advance Beneficiary Notice (ABN) If you have Original Medicare, your health care provider or supplier may give you a notice called an “Advance Beneficiary Notice” (ABN). ■■This notice says Medicare probably (or certainly) won’t pay for some services in certain situations. ■■You will be asked to choose whether to get the items or services listed on the ABN. ■■If you choose to get the items or services listed on the ABN, you will have to pay if Medicare doesn’t. ■■You will be asked to sign the ABN to say that you have read and understood the notice. ■■An ABN isn’t an official denial of coverage by Medicare. You could choose to get the items listed on the ABN and still ask your health care provider or supplier to submit the bill to Medicare or another insurer. If Medicare denies payment, you can still file an appeal. However, you will have to pay for the items or services on appeal if Medicare determines that the items or services aren’t covered (and no other insurer is responsible for payment). ■■You may also get an ABN for other reasons, such as when your doctor or health care provider reduces your home health care. ■■If you should have received an ABN but didn’t, in most cases your provider should refund you for what you paid for the item or service. However, you still must pay any copayments and/or deductibles that apply. If you are in a Medicare plan, call your plan to find out if a service or item will be covered. For more information about ABNs, visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet, “Your Medicare Rights and Protections,” or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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Section 4—Protecting Yourself and Medicare
Appealing Your Medicare Drug Plan’s Decisions If you have Medicare prescription drug coverage (Part D), you have the right to do all of the following (even before you buy a particular drug): ■■Get a written explanation (called a “coverage determination”) from your Medicare drug plan. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it. ■■Ask your drug plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs. ■■Ask for an exception if you or your prescriber believes that a coverage rule (such as prior authorization) should be waived. ■■Ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believes you can’t take any of the lower tier drugs for the same condition. You or your prescriber must contact your plan to ask for a coverage determination or an exception. If your network pharmacy can’t fill a prescription as written, the pharmacist will show you a notice that explains how to contact your Medicare drug plan so you can make your request. If the pharmacist doesn’t show you this notice, ask to see it. A standard request for a coverage determination or exception must be made in writing unless your plan accepts requests by phone. You or your prescriber can call or write your plan for an expedited (fast) request. Your request will be expedited if you haven’t received the prescription and your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting. If you are requesting an exception, your prescriber must provide a statement explaining the medical reason why similar drugs covered by your plan won’t work or may be harmful to you.
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Appealing Your Medicare Drug Plan’s Decisions (continued) Once your Medicare drug plan gets your request for a coverage determination or your prescriber’s statement, the Medicare drug plan has 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you of its decision. If the drug plan doesn’t give you a prompt decision, and you can show that the delay would affect your health, the plan’s failure to act is considered a coverage determination. If you disagree with your Medicare drug plan’s coverage determination or exception decision, you can appeal. There are five levels of appeals available to you. The first level is appealing through your plan.
Appealing Your Drug Plan’s Coverage Determination Decision ■■You, your representative, or your prescriber can appeal your drug plan’s coverage determination decision. ■■The appeal request must be made within 60 days of the drug plan’s decision. ■■A standard request must be made in writing, unless your Medicare drug plan accepts requests by phone. ■■You, your representative, or your prescriber can call or write your plan for an expedited request. ■■The Medicare drug plan has 7 days (for a standard request) or 72 hours (for an expedited request) from the date it gets your request to notify you of its decision. You may have additional appeal rights if you don’t agree with the plan’s decision. ■■You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number. Blue words in the text are defined on pages 115–118.
If your plan doesn’t respond to your request for a coverage determination, an exception, or an appeal, you can file a complaint. Call your plan or 1-800-MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048. After you appeal through your plan, you will get a notice explaining the next level of appeal. If you disagree with the plan’s decision, you can ask for an independent review of your case. For more information about your rights and the different levels of appeals, visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet, “Your Medicare Rights and Protections,” or call 1-800-MEDICARE.
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How Medicare Uses Your Personal Information You have the right to have your personal and health information kept private. The next two pages describe how your information may be used and given out and explain how you can get this information. Notice of Privacy Practices for Original Medicare
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. By law, Medicare is required to protect the privacy of your personal medical information. Medicare is also required to give you this notice to tell you how Medicare may use and give out (“disclose”) your personal medical information held by Medicare. Medicare must use and give out your personal medical information to provide information to the following: ■■ To you or someone who has the legal right to act for you (your personal representative) ■■ To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected ■■ Where required by law Medicare has the right to use and give out your personal medical information to pay for your health care and to operate the Medicare Program. Examples include the following: ■■ Companies that pay bills for Medicare use your personal medical information to pay or deny your claims, to collect your premiums, to share your benefit payment with your other insurer(s), or to prepare your Medicare Summary Notice. ■■ Medicare may use your personal medical information to make sure you and other people with Medicare get quality health care, to provide customer service to you, to resolve any complaints you have, or to contact you about research studies. Medicare may use or give out your personal medical information for the following purposes under limited circumstances: ■■ To State and other Federal agencies that have the legal right to receive Medicare data (such as to make sure Medicare is making proper payments and to assist Federal/State Medicaid programs) ■■ For public health activities (such as reporting disease outbreaks) ■■ For government health care oversight activities (such as fraud and abuse investigations) ■■ For judicial and administrative proceedings (such as in response to a court order) ■■ For law enforcement purposes (such as providing limited information to locate a missing person) ■■ For research studies, including surveys, that meet all privacy law requirements (such as research related to the prevention of disease or disability) ■■ To avoid a serious and imminent threat to health or safety ■■ To contact you about new or changed coverage under Medicare ■■ To create a collection of information that can no longer be traced back to you
Section 4—Protecting Yourself and Medicare
How Medicare Uses Your Personal Information (continued) By law, Medicare must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that isn’t set out in this notice. You may take back (“revoke”) your written permission anytime, except to the extent that Medicare has already acted based on your permission. By law, you have the right to take these actions: ■■ See and get a copy of your personal medical information held by Medicare. ■■ Have your personal medical information amended if you believe that it is wrong or if information is missing, and Medicare agrees. If Medicare disagrees, you may have a statement of your disagreement added to your personal medical information. ■■ Get a listing of those getting your personal medical information from Medicare. The listing won’t cover your personal medical information that was given to you or your personal representative, that was given out to pay for your health care or for Medicare operations, or that was given out for law enforcement purposes. ■■ Ask Medicare to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address). ■■ Ask Medicare to limit how your personal medical information is used and given out to pay your claims and run the Medicare Program. Please note that Medicare may not be able to agree to your request. ■■ Get a separate paper copy of this notice. Visit www.medicare.gov for more information on the following: ■■ Exercising your rights set out in this notice. ■■ Filing a complaint, if you believe Original Medicare has violated these privacy rights. Filing a complaint won’t affect your coverage under Medicare. You can also call 1-800-MEDICARE (1-800-633-4227) to get this information. Ask to speak to a customer service representative about Medicare’s privacy notice. TTY users should call 1-877-486-2048. You may file a complaint with the Secretary of the Department of Health and Human Services. Call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1‑800‑537‑7697. You can also visit www.hhs.gov/ocr/privacy. By law, Medicare is required to follow the terms in this privacy notice. Medicare has the right to change the way your personal medical information is used and given out. If Medicare makes any changes to the way your personal medical information is used and given out, you will get a new notice by mail within 60 days of the change. The Notice of Privacy Practices for Original Medicare became effective April 14, 2003.
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Protect Yourself from Fraud and Identity Theft Identity theft is a serious crime. Identity theft happens when someone uses your personal information without your consent to commit fraud or other crimes. Personal information includes things like your name and your Social Security, Medicare, or credit card numbers. Don’t be a victim of identity theft. Guard against identity theft by taking action to protect yourself.
Blue words in the text are defined on pages 115–118.
Keep your personal information safe. You have control over when you provide and who you allow to have your personal information. Generally, no one should call you or come to your home uninvited to get you to join a Medicare plan. Don’t give your personal information to someone who does this. Only give personal information like your Medicare number to doctors, other health care providers, and plans approved by Medicare; any insurer who pays benefits on your behalf; and to people in the community who work with Medicare, like your State Health Insurance Assistance Program (SHIP) or Social Security. Call 1-800-MEDICARE (1‑800‑633‑4227) if you aren’t sure if a provider is approved by Medicare. TTY users should call 1‑877‑486‑2048. Medicare plans can’t ask you for credit card or banking information over the telephone, unless you are already a member of that plan. In most cases, Medicare plans can’t call you to ask you to join a plan; instead, you must call them. Call 1-800-MEDICARE to report any plans that ask for your personal information over the telephone or that call to enroll you in a plan. You can also call the Medicare Drug Integrity Contractor at 1‑877‑7SAFERX (1‑877‑772‑3379).
Section 4—Protecting Yourself and Medicare
Protect Yourself from Fraud and Identity Theft (continued) If you think someone is using your personal information without your consent, call your local police department and the Federal Trade Commission’s ID Theft Hotline at 1‑877‑438‑4338 to make a report. TTY users should call 1‑866‑653‑4261. For more information about identity theft or to file a complaint online, visit www.consumer.gov/idtheft. The SMP Program Can Help You The SMP (formerly known as the Senior Medicare Patrol) Program educates and empowers people with Medicare to take an active role in detecting and preventing health care fraud and abuse. There is an SMP Program in every state, the District of Columbia, Guam, the U.S. Virgin Islands, and Puerto Rico. For more information or to find your local SMP Program, visit www.smpresource.org, or call your State Health Insurance Assistance Program (SHIP) to get the telephone number. See pages 110–113 for the SHIP telephone number.
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Protect Yourself and Medicare from Billing Fraud
Blue words in the text are defined on pages 115–118.
Most doctors, pharmacists, plans, and other health care providers who work with Medicare are honest. Unfortunately, there may be some who are dishonest. Medicare is working with other government agencies to protect you and Medicare. Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year. You pay for it with higher premiums. Remember these tips to help prevent billing fraud: ■■Ask questions! You have the right to know everything about your health care including the costs billed to Medicare. ■■Educate yourself about Medicare. Know your rights and what a provider can and can’t bill to Medicare. ■■Be wary of providers who tell you that the item or service isn’t usually covered, but they “know how to bill Medicare” so Medicare will pay. If you believe a Medicare plan or provider has used false information to mislead you, call 1‑800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. When you get health care services, record the dates on a calendar and save the receipts you get from providers. Use the calendar and receipts to check for mistakes on statements you get. These include the Medicare Summary Notice if you have Original Medicare, or similar statements that list the services you got or prescriptions you filled. If you suspect billing fraud, here’s what you can do: 1. Contact your health care provider to be sure the bill is correct. 2. Call 1-800-MEDICARE. 3. Call the fraud hotline of the HHS Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950. You can also email
[email protected]. 4. Call the Medicare Drug Integrity Contractor at 1‑877‑7SAFERX (1‑877‑772‑3379) if you are in a Medicare Advantage Plan or a Medicare Prescription Drug Plan.
Section 4—Protecting Yourself and Medicare
Fighting Fraud Can Pay You may get a reward of up to $1,000 if you meet all these conditions: ■■You report suspected Medicare fraud. ■■The Inspector General’s Office reviews your suspicion. ■■The suspected fraud you report isn’t already being investigated. ■■Your report leads directly to the recovery of at least $100 of Medicare money. For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Note: For your protection, your full Medicare number is no longer printed on your Medicare Summary Notice. The first 5 digits of your number are replaced with “Xs.”
How Medicare Protects You Medicare works with other government agencies to protect Medicare from fraud and to protect you from identity theft. With help from honest health care providers, suppliers, law enforcement, and citizens like you, Medicare is improving its ability to prevent fraud and identity theft. Some dishonest health care providers have been removed from Medicare, and some have gone to jail. These actions are saving money for taxpayers and protecting Medicare for the future. Below and on the next page are other ways Medicare is working to protect you. You Are Protected from Discrimination Every company or agency that works with Medicare must obey the law. You can’t be treated differently because of your race, color, national origin, disability, age, religion, or sex. If you think that you haven’t been treated fairly for any of these reasons, call the Department of Health and Human Services, Office for Civil Rights toll-free at 1‑800‑368‑1019. TTY users should call 1-800-537-7697. You can also visit www.hhs.gov/ocr for more information.
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The Medicare Beneficiary Ombudsman An “ombudsman” is a person who reviews issues and helps to resolve them. The Medicare Beneficiary Ombudsman shares information with the Secretary of Health and Human Services, Congress, and other organizations about what works well and what doesn’t work well in Medicare. The Ombudsman helps improve the quality of the services and care you get from Medicare by reporting problems and making recommendations. The Ombudsman makes sure information about the following is available to all people with Medicare: ■■Your Medicare coverage ■■Information to help you make good health care decisions ■■Your Medicare rights and protections ■■How you can get issues resolved The Ombudsman reviews the concerns raised by people with Medicare through 1-800-MEDICARE (1‑800‑633‑4227) and through your State Health Insurance Assistance Program (SHIP). TTY users should call 1-877-486-2048. For more information about the Medicare Beneficiary Ombudsman, visit www.medicare.gov, and select “Ombudsman.”
SECTION
5
Planning Ahead
T
his section gives you information to help you plan ahead to make important health care choices. Your family, friends, and partners in your community may be an important part of helping you manage and plan for your future health care. Whether it’s helping you plan for long-term care or keeping a copy of your advance directives, be sure to ask for any help you may need from people you trust. Section 5 includes information about the following: Plan for Long-term Care . . . . . . . . . . . . . . . . . . 100–102 Advance Directives (like a living will) . . . . . . . . . . . 103–104
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Plan for Long-Term Care
Blue words in the text are defined on pages 115–118.
Long-term care is a variety of services including medical and non‑medical care for people who have a chronic illness or disability. Non-medical care includes non-skilled personal care assistance, such as help with everyday activities like dressing, bathing, and using the bathroom. Medicare and most health insurance plans, including Medigap (Medicare Supplement Insurance) policies don’t pay for this type of care, also called “custodial care.” Medicare only pays for medically-necessary skilled nursing facility or home health care if you meet certain conditions. Long-term care can be provided at home, in the community, in assisted living, or in a nursing home.
Paying for Long-Term Care Long-term Care Insurance—This type of private insurance policy can help pay for many types of long-term care, including both skilled and non-skilled (custodial) care. Long-term care insurance can vary widely. Some policies may cover only nursing home care. Others may include coverage for a range of services like adult day care, assisted living, medical equipment, and informal home care. Note: Long-term care insurance doesn’t replace your Medicare coverage. Your current or former employer or union may offer long-term care insurance. Current and retired Federal employees, active and retired members of the uniformed services, and their qualified relatives can apply for coverage under the Federal Long-term Care Insurance Program. If you have questions, visit www.opm.gov/insure/ltc, or call the Office of Personnel Management at 1-800-582-3337. Personal Resources—You can use your savings to pay for long‑term care. Some insurance companies let you use your life insurance policy to pay for long-term care. Ask your insurance agent how this works.
Section 5—Planning Ahead
Paying for Long-Term Care (continued) Medicaid—Medicaid is a joint Federal and state program that pays for certain health services for people with limited income and resources. If you qualify, you may be able to get help to pay for nursing home care or other health care costs. See page 82 for more information about Medicaid. Home and Community-based Services Programs—If you are already eligible for Medicaid (or, in some states, would be eligible for Medicaid coverage in a nursing home), you or your family members may be able to get help with the costs of services that help you stay in your home instead of moving to a nursing home. Examples include homemaker services, personal care, and respite care. For more information, contact your State Medical Assistance (Medicaid) office. Call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid” to get the telephone number, or visit www.medicare.gov. TTY users should call 1-877-486-2048. Programs of All-inclusive Care for the Elderly (PACE)—PACE is a Medicare and Medicaid program that allows people who otherwise need a nursing home-level of care to remain in the community. PACE was created as a way to provide you, your family, caregivers, and your health care providers flexibility to meet your health care needs and to help you continue living in the community. PACE provides all the care and services covered by Medicare and Medicaid, as authorized by a team of health professionals, as well as additional medically-necessary care and services not covered by Medicare and Medicaid. PACE provides coverage for prescription drugs, doctor visits, transportation, home care, check-ups, hospital visits, and even nursing home stays whenever necessary. For more information about PACE, visit www.medicare.gov/Publications/Pubs/pdf/11341.pdf to view the fact sheet, “Quick Facts About Programs of All‑inclusive Care for the Elderly.”
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Paying for Long-Term Care (continued)
Blue words in the text are defined on pages 115–118.
Long-Term Care Resources Use the following resources to get more information about long‑term care: ■■Visit www.medicare.gov, and select “Plan for Your Long-term Care Needs.” ■■Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. ■■Visit www.longtermcare.gov to learn more about planning for long-term care. ■■Call your State Insurance Department to get information about long-term care insurance. Call 1-800-MEDICARE to get the telephone number. ■■Call the National Association of Insurance Commissioners at 1-866-470-6242 to get a copy of “A Shopper’s Guide to Long‑term Care Insurance.” ■■Visit the Eldercare Locator at www.eldercare.gov to find your local Aging and Disability Resource Center. You can also call 1‑800‑677‑1116.
Section 5—Planning Ahead
Advance Directives Advance directives are legal documents that allow you to put in writing what kind of health care you would want if you were too ill to speak for yourself. Advance directives most often include the following: ■■A health care proxy (durable power of attorney) ■■A living will ■■After-death wishes Talking with your family, friends, and health care providers about your wishes is important, but these legal documents ensure your wishes are followed. It’s better to think about these important decisions before you are ill or a crisis strikes. A health care proxy (sometimes called a durable power of attorney for health care) is used to name the person you wish to make health care decisions for you if you aren’t able to make them yourself. Having a health care proxy is important because if you suddenly aren’t able to make your own health care decisions, someone you trust will be able to make these decisions for you. A living will is another way to make sure your voice is heard. It states which medical treatment you would accept or refuse if your life is threatened. Dialysis for kidney failure, a breathing machine if you can’t breathe on your own, CPR (cardiopulmonary resuscitation) if your heart and breathing stop, or tube feeding if you can no longer eat are examples of medical treatment you can choose to accept or refuse. In some states, advance directives can also include after-death wishes. This may include choices such as organ and tissue donation.
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Advance Directives (continued) If you already have advance directives, take time now to review them to be sure you are still satisfied with your decisions and your health care proxy is still willing and able to carry out your plans. Find out how to cancel or update them in your state if they no longer reflect your wishes. Make sure to give your new advance directives to your doctors, proxy, and family members. Each state has its own laws for creating advance directives. For more information, contact your health care provider, an attorney, your local Area Agency on Aging, or your state health department. Tips 1. Keep the original copies of your advance directives where they are easily found. 2. Give the person you’ve named as your health care proxy, and other concerned family members or friends, a copy of your advance directives. 3. Give your doctor a copy of your advance directives for your medical record. Provide a copy to any hospital or nursing home you stay in. 4. Carry a card in your wallet that states you have advance directives.
SECTION
6
For More Information (Phone, Web sites, Publications)
M
edicare has free information sources to help you with your Medicare and related questions.
Section 6 includes information about the following: 1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . 106 www.MyMedicare.gov (for your personal Medicare information) . . . . . . . . . . . . . . . . . . . . . 107 www.medicare.gov (for general information) . . . . . . . . . 107 Quality of plans and providers . . . . . . . . . . . . . . . . . . . 108 Medicare publications . . . . . . . . . . . . . . . . . . . . . . . 109 If you have a question or complaint about the quality of a Medicare-covered service, call your local Quality Improvement Organization (QIO). Call 1-800-MEDICARE (1‑800‑633‑4227) to get your QIO’s telephone number. TTY users should call 1‑877‑486‑2048. You can also visit www.medicare.gov.
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1-800-MEDICARE (1-800-633-4227) TTY Users 1-877-486-2048. Get Information 24 Hours a Day, Including Weekends. ■■Speak clearly, and have your Medicare card in front of you. You’ll be asked for your Medicare number to reduce the amount of time it takes to speak to an agent. You can either say your Medicare number or enter the numbers using your telephone keypad. ■■Say “AGENT” at any time to talk to a customer service representative, or use this chart. If you need help in a language other than English or Spanish, let the customer service representative know the language. If you are calling about…
Say …
Medicare prescription drug coverage
“Drug Coverage”
Claim or billing issues, or appeals
“Claims” or “Billing”
Preventive services
“Preventive Services”
Help paying health or prescription drug costs
“Limited Income”
Forms or publications
“Publications”
Telephone numbers for your State Medical Assistance (Medicaid) office
“Medicaid”
Outpatient doctor’s care
“Doctor Service”
Hospital visit or emergency care
“Hospital Stay”
Equipment or supplies like oxygen, wheelchairs, walkers, or diabetic supplies
“Medical Supplies”
Information about your Part B deductible
“Deductible”
Nursing Home Services
“Nursing Home”
People who get benefits from the RRB should call 1-800-833-4455 with questions about Part B services and bills. Note: If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing. You can fill out a “Medicare Authorization to Disclose Personal Health Information” form. You can do this by visiting www.medicare.gov or by calling 1-800-MEDICARE to get a copy of the form.
Section 6—For More Information
Go Online to Get the Information You Need Need Personalized Information? Register at www.MyMedicare.gov, Medicare’s secure online service for accessing your personal Medicare information: ■■Complete your Initial Enrollment Questionnaire so your bills get paid correctly. ■■Track your health care claims. ■■Check your Part B deductible status. ■■View your eligibility information. ■■Track the preventive services you can get. ■■Find a Medicare health or prescription drug plan. ■■Keep your Medicare information in one convenient place. ■■Sign up to get your “Medicare & You” handbook electronically.
Need General Information about Medicare? Visit www.medicare.gov: ■■Get detailed information about the Medicare health and prescription drug plans in your area, including what they cost and what services they provide. ■■Find doctors or other health care providers and suppliers who participate in Medicare. ■■See what Medicare covers, including preventive services. ■■Get Medicare appeals information and forms. ■■Get information about the quality of care provided by plans, nursing homes, hospitals, home health agencies, and dialysis facilities. ■■Look up helpful Web sites and telephone numbers. ■■View Medicare publications. If you don’t have a computer, your local library or senior center may be able to help you look up this information. You can also call your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number.
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Compare the Quality of Plans and Providers You can’t always plan ahead when you need health care, but when you can, take time to compare. Medicare collects information about the quality of care and services given by most Medicare plans and other health care providers and information about the experiences of people with the care and services they get. Now you can compare the quality of care and services given by health and prescription drug plans, or health care providers nationwide by visiting www.medicare.gov or by calling your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number. When you, a family member, friend, or SHIP counselor visit Medicare’s Web site, select one of the following: ■■“Compare Health Plans and Medigap Policies” ■■“Compare Medicare Prescription Drug Plans” ■■“Compare Dialysis Facilities” ■■“Compare Home Health Agencies” ■■“Compare Hospitals” ■■“Compare Nursing Homes” These search tools on www.medicare.gov give you a “snapshot” of the quality of care and services some plans and providers give. Find out more about the quality of care and services by doing the following: ■■Ask what your plan or provider does to ensure and improve the quality of care and services. Every plan and health care provider should have someone you can talk to about quality. ■■Ask your doctor what he or she thinks about the quality of care or services the plan or other health care provider gives. Talk to your doctor about Medicare’s information on the quality of care and services that plans and providers give.
Section 6—For More Information
Medicare Publications To read, print, or download copies of booklets, brochures, or fact sheets on the topics listed below or to see what’s available, visit www.medicare.gov and select “Find a Medicare Publication.” You can search by keyword (such as “rights” or “mental health”), or select “View All Medicare Publications.” If the publication you want has a check box after “Order Publication,” you can have a printed copy mailed to you. You can also call 1-800-MEDICARE (1-800-633-4227), and say “Publications” to find out if a printed copy can be mailed to you. TTY users should call 1-877-486-2048.
Blue words in the text are defined on pages 115–118.
Search for free booklets on Medicare topics like the following: ■■Ambulance coverage ■■Kidney dialysis and transplant services ■■Choosing a nursing home ■■Medicare Advantage Plan options ■■Comparing plans and health care providers ■■Medicare prescription drug coverage, including Extra Help ■■Coverage outside the U.S. ■■Mental health care ■■Fighting fraud ■■Preventive services ■■Home health care ■■Rights and protections ■■Hospice care ■■Skilled nursing facility care ■■Hospital quality
ask
Medicare
Do you help someone with Medicare? Medicare has two new resources to help you get the information you need. ■■Visit “Ask Medicare” at www.medicare.gov/caregivers to help your loved one choose a drug plan, compare nursing homes, get help with billing, and more! ■■Sign up for the free bi-monthly “Ask Medicare” electronic newsletter (e-Newsletter) when you go to the site mentioned above. The e-Newsletter has the latest information including important dates, Medicare changes, and resources in your community.
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State Health Insurance Assistance Program (SHIP): For help with questions about appeals, buying other insurance, choosing a health plan, buying a Medigap policy, and Medicare rights and protections.
This page has been intentionally left blank. The printed version contains phone number information. For the most recent phone number information, please visit www.medicare.gov/contacts/home.asp. Thank you.
Section 6—For More Information
This page has been intentionally left blank. The printed version contains phone number information. For the most recent phone number information, please visit www.medicare.gov/contacts/home.asp. Thank you.
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This page has been intentionally left blank. The printed version contains phone number information. For the most recent phone number information, please visit www.medicare.gov/contacts/home.asp. Thank you.
Section 6—For More Information
This page has been intentionally left blank. The printed version contains phone number information. For the most recent phone number information, please visit www.medicare.gov/contacts/home.asp. Thank you.
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Notes
SECTION
7
Definitions Benefit Period—The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods. Coinsurance—An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment—An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
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Section 7—Definitions Creditable Prescription Drug Coverage—Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later. Critical Access Hospital—A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas. Custodial Care—Nonskilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care. Deductible—The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Extra Help—A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Inpatient Rehabilitation Facility—A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients. Institution—A facility that provides short‑term or long‑term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, such as an assisted living facility, or group home are not considered institutions for this purpose. Lifetime Reserve Days—In Original Medicare, these are additional days that Medicare will pay for when you are in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Section 7—Definitions Long-Term Care Hospital—Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management. Medically Necessary—Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. Medicare-Approved Amount—In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges. Medicare Health Plan—A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term is used throughout this handbook to include all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). Medicare Plan—Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans. Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Primary Care Doctor—Your primary care doctor is the doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
117
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Section 7—Definitions Quality Improvement Organization (QIO)—A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to people with Medicare. Referral—A written order from your primary care doctor for you to see a specialist or to get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services. Service Area—A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non‑emergency) services. The plan may disenroll you if you move out of the plan’s service area. Skilled Nursing Facility (SNF) Care—Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include, physical therapy or intravenous injections that can only be given by a registered nurse or doctor. TTY—A teletypewriter (TTY) is a communication device used by people who are deaf, hard-of-hearing, or have a severe speech impairment. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.
Medicare Costs
119
Medicare Costs Your Monthly Premiums for Medicare Part A (Hospital Insurance) Monthly Premium Most people don’t pay a Part A premium because they paid Medicare taxes while working. In 2010, you pay up to $461 each month if you don’t get premium-free Part A. If you pay a late enrollment penalty, this amount is higher. Part B (Medical Insurance) Monthly Premium (See page 21.) If Your Yearly Income in 2008 was File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $85,001–$107,000 $170,001–$214,000 $107,001–$160,000 $214,001–$320,000 $160,001–$214,000 $320,001–$428,000 above $214,000 above $428,000
You Pay $110.50* $154.70 $221.00 $287.30 $353.60
* Most people will continue to pay the 2009 Part B premium of $96.40 in 2010. If you have questions about your Part B premium, call Social Security at 1‑800‑772‑1213. TTY users should call 1‑800‑325‑0778. Note: If you don’t get Social Security, RRB, or Civil Service benefit payments and choose to sign up for Part B, you will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179-0355. If you get a bill from the RRB, mail your premium payments to RRB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197-9024. Part C and Part D (Medicare Health and Prescription Drug Plan) Monthly Premium Contact the plans you’re interested in for the actual plan premium. You also pay the Part B premium (and Part A if you don’t get it premium‑free).
120
Medicare Costs
What you pay if you have Original Medicare Part A Costs for Covered Services and Items In most cases, the hospital gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated. You pay: Home Health Care ■■$0 for home health care services ■■20% of the Medicare-approved amount for durable medical equipment You pay: Hospice Care ■■$0 for hospice care ■■A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management ■■5% of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest) Blood
Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home). In 2010, you pay: Hospital Stay ■■$1,100 deductible and no coinsurance for days 1–60 each benefit period ■■$275 per day for days 61–90 each benefit period ■■$550 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over your lifetime) ■■All costs for each day after the lifetime reserve days ■■Inpatient mental health care in a psychiatric hospital limited to 190 days in a lifetime See “Medical and Other Services” on page 121 for what you pay for doctor services while you are a hospital inpatient. In 2010, you pay: Skilled Nursing ■■$0 for the first 20 days each benefit period Facility Stay ■■$137.50 per day for days 21–100 each benefit period ■■All costs for each day after day 100 in a benefit period Note: If you are in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those noted above. Check with your plan.
Medicare Costs
121
What you pay if you have Original Medicare (continued) Part B Costs for Covered Services and Items Part B Deductible
In 2010, you pay the first $155 yearly for Part B-covered services or items.
Blood
In most cases, the provider gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.
Clinical Laboratory Services Home Health Services
You pay $0 for Medicare-approved services.
Medical and Other Services
You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you are a hospital inpatient), outpatient therapy*, most preventive services, and durable medical equipment.
Mental Health Services
You pay 45% of the Medicare-approved amount for most outpatient mental health care.
Other Covered Services Outpatient Hospital Services
You pay copayment or coinsurance amounts.
You pay $0 for Medicare-approved services. You pay 20% of the Medicare-approved amount for durable medical equipment.
You pay a coinsurance or copayment amount that varies by service for each individual outpatient hospital service. No copayment for a single service can be more than the amount of the inpatient hospital deductible.
*In 2010, there may be limits on physical therapy, occupational therapy, and speech‑language pathology services. If so, there may be exceptions to these limits. Note: All Medicare Advantage Plans must cover these services. Costs vary by plan and may be either higher or lower than those noted above. Check with your plan.
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Medicare Costs Part C and Part D (Medicare Health and Prescription Drug Plans) Costs for Covered Services and Supplies Cost information for the Medicare plans in your area is available by visiting www.medicare.gov. You can also contact the plan, or call 1-800-MEDICARE (1‑800-633-4227). TTY users should call 1-877-486-2048. You can also call your State Health Insurance Assistance Program (SHIP). See pages 110–113 for the telephone number. Medicare Advantage Plans (like an HMO or PPO) must cover all Part A and Part B-covered services and supplies. Check your plan’s materials for actual amounts. The figures below are used to estimate the Part D late enrollment penalty. The national base beneficiary premium amount can change each year. For more information about estimating your penalty amount, see page 67.
2010 Part D National Base Beneficiary Premium 1% Penalty Calculation
$31.94 $.32
Medicare cares about what you think. If you have general comments about this handbook, call 1-800-MEDICARE or email us at
[email protected]. We won’t be able to respond to your comments about the handbook, but we will consider your feedback when writing future versions.
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Using Computers to Manage Your Health Information You can help manage your health information and improve how you communicate with your doctors and other health care providers by using a computer. Computers can also help you get and share access to your health information like never before. This technology (also called Health Information Technology or Health IT) reduces paperwork, medical errors, and health care costs and can also help improve your quality of care. Electronic Health Records (EHRs)—An EHR is a record with important information about your health and treatment (like lab reports) that are maintained and used by your doctor, your doctor’s staff, or a hospital. ■■EHRs can help all of your providers have the same information about your conditions, treatments, tests, and prescriptions. ■■EHRs can help lower the chances of medical errors and can help improve your overall quality of care. Personal Health Records (PHRs)—A PHR is a record with information about your health that you maintain and keep for easy reference. ■■These easy‑to‑use online tools can help you manage your health information from anywhere you have internet access. ■■With a PHR, you can keep track of health information, like the date of your last physical, major illnesses, operations, allergies, or a list of your medicines. ■■PHRs are often offered by providers, health plans, and private companies. Some are free, while others charge a monthly or annual fee. Visit www.medicare.gov/phr to learn more. Electronic Prescribing (eRx)—A way for your prescribers (your doctor or other health care provider who is legally allowed to write prescriptions) to send your prescriptions to your pharmacy using a secure computer. ■■Electronic prescribing lets your prescribers send secure electronic prescriptions directly to your pharmacy, instead of writing prescriptions on paper. ■■Electronic prescribing helps to avoid harmful drug interactions and allows your prescriber to see what drugs your plan offers, including lower‑cost generics. Ask your prescribers if they prescribe electronically. There are strict rules about protecting the privacy and security of electronic information. When you use a secure Web site, you usually have to create a unique user ID and password, and the information you type is encrypted (put in code) so other people can’t read it. More work is being done to make sure that this new technology is even more secure.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 Official Business Penalty for Private Use, $300 CMS Product No. 10050 January 2010
National Medicare Handbook
■■ Also available in Spanish, Braille, Audiotape, and Large Print (English and Spanish). ■■ Suspect fraud? Call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950. ■■ New address? Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. ■■ ¿Necesita usted una copia de este manual en Español? Llame GRATIS al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deberán llamar al 1-877-486-2048.
www.medicare.gov 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048
10% recycled paper
CENTERS FOR MEDICARE & MEDICAID SERVICES
2010
Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare This official government guide has important information about the following: •
What a Medigap (Medicare Supplement Insurance) policy is
•
What’s new in 2010
•
What Medigap policies cover
•
Your rights to buy a Medigap policy
•
How to buy a Medigap policy
This guide can help if you’re thinking about buying, or already have, a Medigap policy.
Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC)
How to use this guide There are two ways to find the information you need: 1. The “Table of contents” on pages 1–2 can help you find the sections you need. 2. The “List of topics” on pages 55–58 lists topics in this guide and the page number of where to find them.
Who should read this guide? This guide helps people with Medicare understand Medigap (also called “Medicare Supplement Insurance”) policies. A Medigap policy is a type of private insurance that helps you pay for some of the costs that Original Medicare doesn’t cover.
What’s new and important in 2010? New laws have brought many changes to Medigap (Medicare Supplement Insurance) policies. These changes give you choices in health care coverage to fill gaps in services that Original Medicare doesn’t cover. • Basic Benefits – Starting with policies effective on or after June 1, 2010, Hospice Part A coinsurance (outpatient prescription drug and inpatient respite care coinsurance) will be covered as a basic benefit. Plan K will cover 50%, and Plan L will cover 75% of these costs. • Part B Coinsurance – Plans K, L, and N will require you to pay a portion of Part B coinsurance and copayments, which may result in lower premiums for these plans. All other Medigap policies pay Part B coinsurance or copayments at 100%. • New Plans Offered – Plans M and N are new choices. • Plans D and G – Plans D and G bought on or after June 1, 2010 have different benefits than D or G plans bought before June 1, 2010. But, if you bought Plan D or G before June 1, 2010, you can keep that plan and the benefits won’t change. • Plans No Longer for Sale – Plans E, H, I, and J will no longer be sold after May 31, 2010. But, if you already have or you buy Plan E, H, I, or J before June 1, 2010, you can keep that plan.
Table of contents
Section 1: Medicare basics A brief look at Medicare ........................................................................ 3–8 Section 2: Medigap basics What is a Medigap policy? ......................................................................... 9 Medigap Plans with effective dates through May 31, 2010 .......... 10–11 Medigap Plans effective on or after June 1, 2010 ........................... 12–13 What Medigap policies don’t cover......................................................... 14 Types of coverage that are NOT Medigap policies ............................... 14 What types of Medigap policies can insurance companies sell? ... 14–15 What do I need to know if I want to buy a Medigap policy? ....... 15–16 When is the best time to buy a Medigap policy?.............................16–17 Why is it important to buy a Medigap policy when I’m first eligible? .............................................................................................. 18 How insurance companies set prices for Medigap policies .......... 19–20 Comparing Medigap costs ....................................................................... 21 What is Medicare SELECT? .................................................................... 22 How does Medigap pay your Medicare Part B bills? ............................ 22 Section 3: Your right to buy a Medigap policy Guaranteed issue rights (Medigap protections) ............................. 23–26 (This section includes the situations when you have the right to buy a Medigap policy after your open enrollment period.) Section 4: Steps to buying a Medigap policy Step-by-step guide to buying a Medigap policy ............................. 27–32 Section 5: For people who already have a Medigap policy Switching Medigap policies ............................................................... 34–37 Losing Medigap coverage.......................................................................... 38 Medigap policies and Medicare prescription drug coverage.........38–40
Continued on next page
1
2
Table of contents
Section 6: Medigap policies for people with a disability or ESRD Information for people under 65 ...................................................... 41–42 Section 7: Medigap coverage in Massachusetts, Minnesota, and Wisconsin Medigap policies for Massachusetts ........................................................ 44 Medigap policies for Minnesota .............................................................. 45 Medigap policies for Wisconsin............................................................... 46 Section 8: For more information Where to get more information............................................................... 47 How to get help with Medicare and Medigap questions ..................... 48 State Health Insurance Assistance Program and State Insurance Department .........................................................................................49–50 (Telephone numbers for each state) Section 9: Definitions Where words in blue are defined.......................................................51–54 Section 10: List of topics An alphabetical list of what’s in this guide.......................................55–58
3
SECTION
1
Medicare basics
This guide helps people with Medicare understand Medigap (also called “Medicare Supplement Insurance”) policies. A Medigap policy is health insurance sold by private insurance companies to fill gaps in Original Medicare coverage. Medigap policies can help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. Some Medigap policies also cover certain benefits Original Medicare doesn’t cover. Medigap policies don’t cover your share of the costs under other types of health coverage, including Medicare Advantage Plans, stand-alone Medicare Prescription Drug Plans, employer/union group health coverage, Medicaid, Veterans Administration (VA) benefits, or TRICARE. Also, except for Medicare Prescription Drug Plans, while you have any of these other types of health coverage, insurance companies generally aren’t allowed to sell you a Medigap policy. Before you learn more about Medigap policies, the next few pages provide a brief look at Medicare. If you already know the basics about Medicare and want to learn about Medigap, turn to page 9.
4
Section 1: Medicare basics
What is Medicare? Medicare is health insurance for people 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). Original Medicare covers many health care services and supplies, but there are many costs (“gaps”) it doesn’t cover.
The Different Parts of Medicare The different parts of Medicare help cover specific services if you meet certain conditions. Medicare has the following parts: Medicare Part A (Hospital Insurance) • Helps cover inpatient care in hospitals • Helps cover skilled nursing facility, hospice, and home health care Medicare Part B (Medical Insurance) • Helps cover doctors’ services and outpatient care • Helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO) • A health coverage option run by private companies approved by and under contract with Medicare • Includes Part A, Part B, and usually other coverage like prescription drugs Medicare Part D (Medicare Prescription Drug Coverage) • A prescription drug option run by private insurance companies approved by and under contract with Medicare • Helps cover the cost of prescription drugs • May help lower your prescription drug costs and help protect against higher costs in the future
Section 1: Medicare basics
5
Your Medicare Coverage Choices With Medicare, you can choose how you get your health and prescription drug coverage. Below are brief descriptions of your coverage choices. Original Medicare • Run by the Federal government. • Provides your Part A and Part B coverage. • You can buy a Medigap (Medicare Supplement Insurance) policy (sold by private insurance companies) to help fill the gaps in Part A and Part B coverage (like coinsurance, copayments, and deductibles). • You can join a Medicare Prescription Drug Plan to add drug coverage. Medicare Advantage Plans (like an HMO or PPO)—see page 6. • Run by private insurance companies approved by and under contract with Medicare. • Provide your Part A and Part B coverage, but can charge different amounts for certain services. May offer extra coverage and prescription drug coverage for an extra cost. Costs for items and services vary by plan. • If you want drug coverage, you must get it through your plan (in most cases). • If you’re enrolled in a Medicare Advantage Plan, you don’t need and can’t use a Medigap policy. Other Medicare Health Plans
Words in blue are defined on pages 51–54.
• Plans that aren’t Medicare Advantage Plans but are still part of Medicare. • Include Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE). • Most plans provide Part A and Part B coverage, and some also provide prescription drug coverage (Part D). Note: If you have other health and/or prescription drug coverage from a former or current employer or union, you may have other coverage choices. This coverage may affect which Medicare coverage choice is best for you. For more information about your Medicare coverage choices, call 1-800-MEDICARE (1-800-633-4227), or visit www.medicare.gov. TTY users should call 1-877-486-2048. You can also contact your State Health Insurance Assistance Program (SHIP). See pages 49–50 for the telephone number.
6
Section 1: Medicare basics
Medicare Advantage Plans Medicare Advantage Plans include the following: • Health Maintenance Organization (HMO) Plans • Preferred Provider Organization (PPO) Plans • Private Fee-for-Service (PFFS) Plans • Medical Savings Account (MSA) Plans • Special Needs Plans (SNP) Medicare Advantage Plans and Medigap Policies If you have a Medigap policy and you are switching from Original Medicare to a Medicare Advantage Plan, you don’t need and can’t use the Medigap policy to cover deductibles, copayments, coinsurance, or premiums under the Medicare Advantage Plan. You may choose to drop your Medigap policy, but you should talk to your State Health Insurance Assistance Program (see pages 49–50) and your current Medigap insurance company first because you may not be able to get your Medigap policy back. If you already have a Medicare Advantage Plan, it’s illegal for anyone to sell you a Medigap policy unless you’re disenrolling from your Medicare Advantage Plan to go back to Original Medicare.
Medicare Prescription Drug Coverage (Part D) Medicare offers prescription drug coverage (Part D) for everyone with Medicare. To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by and under contract with Medicare. Each plan can vary in cost and drugs covered. Words in blue If you want Medicare drug coverage, you need to choose a plan that works are defined on with your health coverage. pages 51–54. There are two ways to get Medicare prescription drug coverage: 1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans. 2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that have prescription drug coverage. You get all of your Part A and Part B coverage and prescription drug coverage (Part D) through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”
Section 1: Medicare basics
7
Medicare Prescription Drug Coverage (continued) Medicare Prescription Drug Coverage and Medigap Policies • If you bought your Medigap policy before January 1, 2006, you may have a Medigap policy with prescription drug coverage. You can keep the prescription drug coverage in that policy, or you can join a Medicare Prescription Drug Plan. If you join a Medicare Prescription Drug Plan, you must tell your Medigap insurance company. It will remove the prescription drug coverage from your Medigap policy and adjust your premium. This is because you can’t have both types of prescription drug coverage at the same time. Once the drug coverage is removed, you can’t get that coverage back even though you didn’t change Medigap policies. See pages 38–40 if you have a Medigap policy with prescription drug coverage that you bought before January 1, 2006. • If you have Original Medicare and already have a Medigap policy without prescription drug coverage, you can join a Medicare Prescription Drug Plan, and it won’t affect your Medigap policy. Can I buy a new Medigap policy that includes prescription drug coverage? No. As of January 1, 2006, Medicare offers prescription drug coverage to everyone with Medicare. For this reason, Medigap policies sold on or after January 1, 2006, don’t include prescription drug coverage. If you want prescription drug coverage, you can get this coverage in one of the two ways described on page 6.
For more information Remember, this guide is about Medigap policies. To learn more about Medicare, visit www.medicare.gov/Publications/Pub/pdf/10050.pdf to view the “Medicare & You” handbook. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
8
Section 1: Medicare basics
Notes
Use this page to write down important notes or phone numbers.
9
SECTION
2
Medigap basics
What is a Medigap policy? A Medigap (also called “Medicare Supplement Insurance”) policy is private health insurance that is designed to supplement Original Medicare. This means it helps pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). If you are in Original Medicare and you have a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share. (Note: Medicare doesn’t pay any of the costs for you to get a Medigap policy.) Also, a Medigap policy is different than a Medicare Advantage Plan (like an HMO or PPO) because those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Medicare benefits. Every Medigap policy must follow Federal and state laws designed to protect you, and the policy must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies in most states can only sell you a “standardized” Medigap policy identified by letters A through N. Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it. Cost is usually the only difference between Medigap policies with the same letter sold by different insurance companies. In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. See pages 44–46. In some states, you may be able to buy another type of Medigap policy called Medicare SELECT. See page 22.
10
Section 2: Medigap basics
Information about the chart on page 11 The chart on the next page gives you a quick look at the standardized Medigap Plans (including Medicare SELECT) available for purchase through May 31, 2010, and their benefits. Insurance companies selling Medigap policies are required to make Plan A available. Not all types of Medigap policies may be available in your state. See pages 44–46 if you live in Massachusetts, Minnesota, or Wisconsin. If you need more information, call your State Insurance Department or State Health Insurance Assistance Program. See pages 49–50 for your state’s telephone number. See pages 12–13 for an explanation of these changes and to see plans with benefits effective June 1, 2010.
Important New laws have brought many changes to Medigap policies. These changes will be for plans with effective dates on or after June 1, 2010, and will give you choices in health care coverage to fill gaps in services that Original Medicare doesn’t cover. See pages 12–13 for an explanation of these changes and the plans with benefits effective on or after June 1, 2010.
✓
Preventive Care not Covered by Medicare (up to $120)
✓
Medicare Preventive Care Part B Coinsurance
✓
✓
At-home Recovery (Up to Plan Limits)
✓
✓
✓
✓
✓
✓
After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($155 in 2010), the Medigap plan pays 100% of covered services for the rest of the calendar year. Out-of-pocket limit is the maximum amount you would pay for coinsurance and copayments.
**
✓
✓
✓ ✓
G ✓
80%
Plans F and J also offer a high-deductible plan. This means you must pay for Medicare-covered costs up to the deductible amount of $2,000 in 2010 before your Medigap plan pays anything.
*
✓
✓
✓
✓
✓
✓
✓
✓ ✓
Foreign Travel Emergency (Up to Plan Limits)
✓
✓
✓
✓ ✓
E F* ✓ ✓
✓
✓
✓
✓
✓ ✓
D ✓
✓
✓
✓
✓
✓ ✓
H ✓
✓
✓
✓
✓
✓
✓
✓ ✓
I ✓
✓
✓
✓
✓
✓
✓
✓
✓
✓ ✓
J* ✓
Medigap Plans A through L
Medicare Part B Excess Charges
Medicare Part B Deductible
✓
✓
✓ ✓
Medicare Part A Deductible
✓ ✓
✓ ✓
C ✓
✓
B ✓
A ✓
Skilled Nursing Facility Care Coinsurance
Medigap Benefits Medicare Part A Coinsurance hospital costs up to an additional 365 days after Medicare benefits are used up Medicare Part B Coinsurance or Copayment (Except for preventive services) Blood (First 3 Pints) Hospice Care Coinsurance or Copayment
Through May 31, 2010 you may buy the following Medigap Plans:
✓
75%
75%
75% 75% 75%
L ✓
$4,620
$2,310
Out-of-Pocket Limit**
✓
50%
50%
50% 50% 50%
K ✓
If a checkmark appears in a column of this chart, the Medigap policy covers 100% of the described benefit. If a column lists a percentage, the policy covers that percentage of the described benefit. If a column is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible).
How to read the chart:
Medigap Plans with effective dates through May 31, 2010
Section 2: Medigap basics 11
12
Section 2: Medigap basics
Information about the chart on page 13 The chart on the next page gives you a quick look at the standardized Medigap Plans available with benefits effective June 1, 2010. See page 11 for Medigap Plans (including Medicare SELECT) available for purchase through May 31, 2010 and their benefits.
Important Changes Effective June 1, 2010 New laws have brought many changes to Medigap policies. These changes will be effective June 1, 2010, and will give you choices in health care coverage to fill gaps in services that Original Medicare doesn’t cover. • Basic Benefits – Starting with policies effective on or after June 1, 2010, Hospice Part A coinsurance (outpatient prescription drug and inpatient respite care coinsurance) will be covered. Plan K will cover 50% of the costs and Plan L will cover 75% of these costs. • Part B Coinsurance – Plans K, L, and N will require you to pay a portion of Part B coinsurance and copayments, which may result in lower premiums for these plans. All other Medigap policies pay them at 100%. • New Plans Offered – Plans M and N are new choices. See the chart on page 13 for details. • Plans D and G – Plans D and G effective on or after June 1, 2010 have different benefits than D or G Plans bought before June 1, 2010. • Plans No Longer for Sale – Plans E, H, I, and J will no longer be sold after May 31, 2010. But, if you already have or you buy Plan E, H, I, or J before June 1, 2010, you can keep that plan. Insurance companies selling Medigap policies are required to make Plan A available. If they offer any other Medigap plan, they must also offer either Medigap Plan C or Plan F. Not all types of Medigap policies may be available in your state. See pages 44–46 if you live in Massachusetts, Minnesota, or Wisconsin. If you need more information, call your State Insurance Department or State Health Insurance Assistance Program. See pages 49–50 for your state’s telephone number.
✓
***Plan N pays 100% of the Part B coinsurance except up to $20 copayment for office visits and up to $50 for emergency department visits.
After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($155 in 2010), the Medigap plan pays 100% of covered services for the rest of the calendar year. Out-of-pocket limit is the maximum amount you would pay for coinsurance and copayments.
**
Plan F also offers a high-deductible plan. This means you must pay for Medicare-covered costs up to the deductible amount $2,000 in 2010 before your Medigap plan pays anything.
*
✓
✓
Medicare Preventive Care Part B Coinsurance
✓
✓
✓
✓
Foreign Travel Emergency (Up to Plan Limits)
✓
✓
✓
✓ ✓ ✓
✓
F*
✓
✓
✓
✓
✓ ✓ ✓
✓
D
Medicare Part B Excess Charges
Medicare Part B Deductible
✓
✓ ✓ ✓ ✓
✓
✓ ✓ ✓
✓ ✓ ✓
✓
Medicare Part A Deductible
✓
✓
C
✓
B
A
Skilled Nursing Facility Care Coinsurance
Medigap Benefits Medicare Part A Coinsurance hospital costs up to an additional 365 days after Medicare benefits are used up Medicare Part B Coinsurance or Copayment Blood (First 3 Pints) Part A Hospice Care Coinsurance or Copayment
✓
✓
✓
✓
✓
✓ ✓ ✓
✓
G
✓
75%
75%
75% 75% 75%
✓
L
$4,620
$2,310
Out-of-Pocket Limit**
✓
50%
50%
50% 50% 50%
✓
K
Medigap Plans Effective June 1, 2010
You may buy the following Medigap Plans which become effective June 1, 2010:
✓
✓
50%
✓
✓ ✓ ✓
✓
M
✓
✓
✓
✓
✓*** ✓ ✓
✓
N
If a checkmark appears in a column of this chart, the Medigap policy covers 100% of the described benefit. If a column lists a percentage, the policy covers that percentage of the described benefit. If a column is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible).
How to read the chart:
Medigap Plans Effective on or after June 1, 2010
Section 2: Medigap basics 13
14
Section 2: Medigap basics
What Medigap policies don’t cover Medigap policies don’t cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, and private-duty nursing.
Types of coverage that are NOT Medigap policies • Medicare Advantage Plans (Part C), like an HMO, PPO, or Private Fee-for-Service Plan • Medicare Prescription Drug Plans (Part D) • Medicaid • Employer or union plans, including Federal Employees Health Benefits Program (FEHBP) • TRICARE • Veterans’ benefits • Long-term care insurance policies • Indian Health Service, Tribal, and Urban Indian Health plans
What types of Medigap policies can insurance companies sell? Words in blue are defined on pages 51–54.
In most cases, Medigap insurance companies can sell you only a “standardized” Medigap policy. All Medigap policies must have specific benefits so you can compare them easily. See pages 11 and 13. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 44–46. Insurance companies that sell Medigap policies don’t have to offer every Medigap policy (Medigap Plans A through N). However, they must offer Medigap Plan A if they offer any other Medigap policy. As of June 1, 2010, if they offer any other Medigap policy, they must also offer either Plan C or Plan F. Each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer.
Section 2: Medigap basics
15
What types of Medigap policies can insurance companies sell? (continued) In some cases, an insurance company must sell you a Medigap policy, even if you have health problems. Listed below are certain times that you’re guaranteed the right to buy a Medigap policy: • When you’re in your Medigap open enrollment period. See pages 16–17. • If you have a guaranteed issue right. See pages 23–25. You may also buy a Medigap policy at other times, but the insurance company can deny you a Medigap policy based on your health. Also, in some cases it may be illegal for the insurance company to sell you a Medigap policy (such as if you already have Medicaid or a Medicare Advantage Plan).
What do I need to know if I want to buy a Medigap policy? • You must have Medicare Part A and Part B to buy a Medigap policy. • Plans E, H, I, and J will no longer be for sale after May 31, 2010. • Effective June 1, 2010, there will be two new Medigap Plans offered—Plans M and N. In addition, benefits for Plans A, B, C, D, F, and G will change. • You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare. • A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you each will have to buy separate Medigap policies. • You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one. • If you want to buy a Medigap policy, follow the “Steps to buying a Medigap policy.” See pages 27–32. • If you want to drop your Medigap policy, contact your insurance company to cancel the policy. • Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
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Section 2: Medigap basics
What do I need to know if I want to buy a Medigap policy? (continued) • Although some Medigap policies sold in the past cover prescription drugs, Medigap policies sold after January 1, 2006, aren’t allowed to include prescription drug coverage. • If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D) offered by private companies approved by Medicare. See page 6. To learn about Medicare prescription drug coverage, visit www.medicare.gov/Publications/Pubs/pdf/11109.pdf to view the booklet “Your Guide to Medicare Prescription Drug Coverage,” or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
When is the best time to buy a Medigap policy?
Words in blue are defined on pages 51–54.
The best time to buy a Medigap policy is during your Medigap open enrollment period. This period lasts for 6 months and begins on the first day of the month in which you are both 65 or older and enrolled in Medicare Part B. Some states have additional open enrollment periods including those for people under 65. During this period, an insurance company can’t use medical underwriting. This means the insurance company can’t do any of the following: • Refuse to sell you any Medigap policy it sells • Make you wait for coverage to start (except as explained below) • Charge you more for a Medigap policy because of your health problems While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage of a pre-existing condition. A pre-existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a “pre-existing condition waiting period.” Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. After this 6-month period, the Medigap policy will cover the condition that was excluded. Remember, for Medicare-covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out-of-pocket costs.
Section 2: Medigap basics
When is the best time to buy a Medigap policy? (continued) Even if you have a pre-existing condition, if you buy a Medigap policy during your Medigap open enrollment period and if you recently had certain kinds of health coverage called “creditable coverage,” it’s possible to avoid or shorten waiting periods for pre-existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you have had at least 6 months of continuous prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre-existing conditions. There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they will only count if you didn’t have a break in coverage for more than 63 days. If there was any time that you had no health coverage of any kind and were without coverage for more than 63 days, you can only count creditable coverage you had after that break in coverage. Talk to your Medigap insurance company. It will be able to tell you if your previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program. See pages 49–50. If you buy a Medigap policy when you have a guaranteed issue right (also called “Medigap protection”), the insurance company can’t use a pre-existing condition waiting period. See pages 23–25 for more information about guaranteed issue rights. Note: You can send in your application for a Medigap policy before your Medigap open enrollment period starts. This may be important if you currently have coverage that will end when you turn 65. This will allow you to have continuous coverage.
17
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Section 2: Medigap basics
Why is it important to buy a Medigap policy when I am first eligible? It’s very important to understand your Medigap open enrollment period. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you apply for Medigap coverage after your open enrollment period, there is no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you are eligible because of one of the limited situations listed on pages 24–25. It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap open enrollment period begins when you enroll in Part B, and can’t be changed or repeated. In most cases it makes sense to enroll when you are first eligible for Part B, because you might otherwise have to pay a Part B late enrollment penalty.
Words in blue are defined on pages 51–54.
However, if you have group health coverage through an employer or union, because either you or your spouse is currently working, you may want to wait to enroll in Part B. This is because employer plans often provide coverage similar to Medigap, so you don’t need a Medigap policy. When your employer coverage ends, you’ll get a chance to enroll in Part B without a late enrollment penalty which means your Medigap open enrollment period will start when you’re ready to take advantage of it. If you enrolled in Part B while you still had the employer coverage, your Medigap open enrollment period would start, and unless you bought a Medigap policy before you needed it, you would miss your open enrollment period entirely.
Section 2: Medigap basics
How insurance companies set prices for Medigap policies Each insurance company decides how it will set the price, or premium, for its Medigap policies. It’s important to ask how an insurance company prices its policies. The way they set the price affects how much you pay now and in the future. Medigap policies can be priced or “rated” in three ways: 1. Community-rated (also called “no-age-rated”) 2. Issue-age-rated (also called “entry-age-rated”) 3. Attained-age-rated Each of these ways of pricing Medigap policies is described in the chart on the next page. The examples show how your age affects your premiums, and why it’s important to look at how much the Medigap policy will cost you now and in the future. The amounts in the examples aren’t actual costs. Other factors such as geographical rating, medical underwriting, and discounts can also affect the amount of your premiums.
19
20
Section 2: Medigap basics
How insurance companies set prices for Medigap policies (continued) Type of pricing
How it’s priced
What this pricing may mean for you
Examples
Communityrated (also called “no-agerated”)
Generally the same monthly premium is charged to everyone who has the Medigap policy, regardless of age.
Your premium isn’t based on your age. Premiums may go up because of inflation and other factors but not because of your age.
Mr. Smith is 65. He buys a Medigap policy and pays a $165 monthly premium.
Issue-agerated (also called “entry age-rated”)
The premium is based on the age you are when you buy (are “issued”) the Medigap policy.
Premiums are lower for people Mr. Han is 65. He buys a Medigap who buy at a younger age and policy and pays a $145 monthly won’t change as you get older. premium. Premiums may go up because Mrs. Wright is 72. She buys the same of inflation and other factors Medigap policy as Mr. Han. Since she but not because of your age. is older when she buys it, her monthly premium is $175.
Attained-age- The premium is based on your rated
current age (the age you have “attained”), so your premium goes up as you get older.
Premiums are low for younger buyers but go up as you get older. They may be the least expensive at first, but they can eventually become the most expensive. Premiums may also go up because of inflation and other factors.
Mrs. Perez is 72. She buys the same Medigap policy as Mr. Smith. She also pays a $165 monthly premium because, with this type of Medigap policy, everyone pays the same price regardless of age.
Mrs. Anderson is 65. She buys a Medigap policy and pays a $120 monthly premium. • At 66, her premium goes up to $126. • At 67, her premium goes up to $132. • At 72, her premium goes up to $165. Mr. Dodd is 72. He buys the same Medigap policy as Mrs. Anderson. He pays a $165 monthly premium. His premium is higher than Mrs. Anderson’s because it’s based on his current age. Mr. Dodd’s premium will go up every year. • At 73, his premium goes up to $171. • At 74, his premium goes up to $177.
Section 2: Medigap basics
21
Comparing Medigap costs As discussed on the previous pages, the cost of Medigap policies can vary widely. There can be big differences in the premiums that different insurance companies charge for exactly the same coverage. As you shop for a Medigap policy, be sure to compare the same type of Medigap policy, and consider the type of pricing used. See pages 19–20. For example, compare a Medigap Plan C from one insurance company with a Medigap Plan C from another insurance company. Although this guide can’t give actual costs of Medigap policies, you can get this information by calling insurance companies or your State Health Insurance Assistance Program. See pages 49–50. You can also find out which insurance companies sell Medigap policies in your area by visiting www.medicare.gov and selecting “Compare Health Plans and Medigap Policies in Your Area.” The cost of your Medigap policy may also depend on whether the insurance company does any of the following: • Offers discounts (such as discounts for women, non-smokers, or people who are married; discounts for paying annually; or discounts for paying your premiums using electronic funds transfer). • Uses medical underwriting, or applies a different premium when you don’t have a guaranteed issue right. • Sells Medicare SELECT policies that may require you to use certain providers. If you buy this type of Medigap policy, your premium may be less. See page 22. • Offers a “high-deductible option” for Medigap Plans F and J. Remember, Plan J will no longer be for sale after May 31, 2010. If you buy a Medigap Plan F or J high-deductible option, you must pay the first $2,000 (in 2010) in Medicare-covered costs before the Medigap policy pays anything. You must also pay a separate deductible ($250 per year) for foreign travel emergency services. If you bought your Medigap Plan J before January 1, 2006, and it still covers prescription drugs, you would also pay a separate deductible ($250 per year) for prescription drugs covered by the Medigap policy.
22
Section 2: Medigap basics
What is Medicare SELECT? Medicare SELECT is a type of Medigap policy sold in some states that requires you to use hospitals and, in some cases, doctors within its network to be eligible for full insurance benefits (except in an emergency). Medicare SELECT can be any of the standardized Medigap Plans A through N. Medicare SELECT policies generally cost less than other Medigap policies. However, if you don’t use a Medicare SELECT hospital or doctor for non-emergency services, you’ll have to pay some or all of what Medicare doesn’t pay. Medicare will pay its share of approved charges no matter which hospital or doctor you choose.
How does Medigap pay your Medicare Part B bills? In most Medigap policies, when you sign the Medigap insurance contract you agree to have the Medigap insurance company get your Medicare Part B claim information directly from Medicare and then pay the doctor directly. Some Medigap insurance companies also provide this service for Medicare Part A claims. If your Medigap insurance company doesn’t provide this service, ask your doctors if they “participate” in Medicare. (This means that they accept “assignment” for all Medicare patients.) If your doctor participates, the Medigap insurance company is required to pay the doctor directly if you request. If you have any questions about Medigap claim filing, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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3
Your right to buy a Medigap policy What are guaranteed issue rights? As explained on pages 16–18, the best time to buy a Medigap policy is during your Medigap open enrollment period, when you have the right to buy any Medigap policy offered in your state. However, even if you aren’t in your Medigap open enrollment period, there are several situations in which you may still have a guaranteed right to buy a Medigap policy. Guaranteed issue rights (also called “Medigap protections”) are rights you have in certain situations when insurance companies are required by law to offer you certain Medigap policies even if you have health problems and must cover any pre-existing conditions. See page 16. These situations are described on pages 24–25. In these situations, an insurance company must do the following: • Sell you a Medigap policy • Cover all your pre-existing health conditions • Can’t charge you more for a Medigap policy because of past or present health problems If you live in Massachusetts, Minnesota, or Wisconsin, you have guaranteed issue rights to buy a Medigap policy, but the Medigap policies are different. See pages 44–46 for your Medigap policy choices.
When do I have guaranteed issue rights? In most cases, you have a guaranteed issue right when you have other health care coverage that changes in some way, such as when you lose the other health care coverage. See pages 24–25. In other cases, you have a “trial right” to try a Medicare Advantage Plan and still buy a Medigap policy if you change your mind. For trial rights, see guaranteed issue rights, Situations #4 and #5 on page 25.
24
Section 3: Your right to buy a Medigap policy
An insurance company can’t refuse to sell you a Medigap policy in the following situations: You have a guaranteed issue right if...
You have the right to buy...
You can/must apply for a Medigap policy...
#1: You are in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan’s service area.
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
As early as 60 calendar days before the date your health care coverage will end, but no later than 63 calendar days after your health care coverage ends. Medigap coverage can’t start until your Medicare Advantage Plan coverage ends.
#2: You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
Note: In this situation, you may have additional rights under state law.
#3: You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy’s service area. You can keep your Medigap policy, or you may want to switch to another Medigap policy.
You only have this right if you switch to Original Medicare rather than joining another Medicare Advantage Plan.
If you have COBRA coverage, you can either buy a Medigap policy right away or wait until the COBRA coverage ends.
No later than 63 calendar days after the latest of these 3 dates: 1. Date the coverage ends 2. Date on the notice you get telling you that coverage is ending (if you get one) 3. Date on a claim denial, if this is the only way you know that your coverage ended
Medigap Plan A, B, C, F, K, or L that is sold by any insurance company in your state or the state you are moving to.
As early as 60 calendar days before the date your health care coverage will end, but no later than 63 calendar days after your health care coverage ends.
Section 3: Your right to buy a Medigap policy
25
An insurance company can’t refuse to sell you a Medigap policy in the following situations: (continued) You have a guaranteed issue right if...
You have the right to buy...
You can/must apply for a Medigap policy...
#4: (Trial Right) You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare.
Any Medigap policy that is sold in your state by any insurance company.
As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends.
#5: (Trial Right) You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time; you have been in the plan less than a year, and you want to switch back.
The Medigap policy you had before you joined the Medicare Advantage Plan or Medicare SELECT policy, if the same insurance company you had before still sells it. If it included drug coverage, you can still get that same policy, but without the drug coverage.
Note: Your rights may last for an extra 12 months under certain circumstances.
As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends. Note: Your rights may last for an extra 12 months under certain circumstances.
If your former Medigap policy isn’t available, you can buy a Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company. #6: Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
No later than 63 calendar days from the date your coverage ends.
#7: You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn’t followed the rules, or it misled you.
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
No later than 63 calendar days from the date your coverage ends.
26
Section 3: Your right to buy a Medigap policy
Can I buy a Medigap policy if I lose my health care coverage? Because you may have a guaranteed issue right (see pages 23–25) to buy a Medigap policy, make sure you keep the following: • A copy of any letters, notices, e-mails, and/or claim denials that have your name on them as proof of coverage • The postmarked envelope these papers come in as proof of when it was mailed You may need to send a copy of some or all of these papers with your Medigap application to prove you have a guaranteed issue right. It’s best to apply for a Medigap policy before your current health coverage ends. You can apply for a Medigap policy while you’re still in your health plan, but your Medigap coverage can only start after your health plan coverage ends. This will prevent breaks in your health coverage.
For more information If you have any questions or want to learn about any additional Medigap rights in your state, you can do the following: • Call your State Health Insurance Assistance Program to make sure that you qualify for these guaranteed issue rights. See pages 49–50. • Call your State Insurance Department if you’re denied Medigap coverage in any of these situations. See pages 49–50. Important: The guaranteed issue rights in this section are from Federal law. These rights are for both Medigap and Medicare SELECT policies. Many states provide additional Medigap rights. There may be times when more than one of the situations in the chart on pages 24–25, applies to you. When this happens, you can choose the guaranteed issue right that gives you the best choice. Some of the situations listed on pages 24–25 include loss of coverage under Programs of All-Inclusive Care for the Elderly (PACE). PACE combines medical, social, and long-term care services, and prescription drug coverage for frail people. To be eligible for PACE, you must meet certain conditions. PACE may be available in states that have chosen it as an optional Medicaid benefit. If you have Medicaid, an insurance company can sell you a Medigap policy only in certain situations. For more information about PACE, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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4
Steps to buying a Medigap policy
Buying a Medigap policy is an important decision. Only you can decide if a Medigap policy is the way for you to supplement Original Medicare coverage and which Medigap policy to choose. Shop carefully. Compare available Medigap policies to see which one meets your needs. As you shop for a Medigap policy, keep in mind that different insurance companies may charge different amounts for exactly the same Medigap policy, and not all insurance companies offer all of the Medigap policies. Below is a step-by-step guide to help you buy a Medigap policy. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 44–46. STEP 1: Decide which benefits you want, then decide which of the Medigap Plans A through N meet your needs. See page 28. STEP 2: Find out which insurance companies sell Medigap policies in your state. See pages 28–29. STEP 3: Call the insurance companies that sell the Medigap policies you’re interested in and compare costs. See pages 30–31. STEP 4: Buy the Medigap policy. See page 32.
28
Section 4: Steps to buying a Medigap policy
STEP 1:
Decide which benefits you want, then decide which of the Medigap Plans A through N meet your needs.
You should think about your current and future health care needs when deciding which benefits you want because you might not be able to switch Medigap policies later. Decide which benefits you need, and select the Medigap policy that will work best for you. The charts on pages 11 and 13 provide an overview of the Medigap benefits.
STEP 2:
Find out which insurance companies sell Medigap policies in your state.
To find out which insurance companies sell Medigap policies in your state, you can do any of the following: • Call your State Health Insurance Assistance Program. See pages 49–50. Ask if they have a “Medigap rate comparison shopping guide” for your state. This type of guide usually lists companies that sell Medigap policies in your state and their costs. • Call your State Insurance Department. See pages 49–50. • Visit www.medicare.gov, and select “Compare Health Plans and Medigap Policies in Your Area.”
Words in blue are defined on pages 51–54.
This website will help you find information on all your health plan options, including the Medigap policies in your area. You can also get information on the following: ✔ How to contact the insurance companies that sell Medigap policies in your state ✔ What each Medigap policy covers ✔ How insurance companies decide what to charge you for a Medigap policy premium If you don’t have a computer, your local library or senior center may be able to help you look at this information. You can also call 1-800-MEDICARE (1-800-633-4227). A customer service representative will help you get information on all your health plan options including the Medigap policies in your area. TTY users should call 1-877-486-2048.
Section 4: Steps to buying a Medigap policy
STEP 2: (continued) Since costs can vary between companies, you should plan to call more than one insurance company that sells Medigap policies in your state. Before you call, check the companies to be sure they are honest and reliable by using one of the resources listed below. • Call your State Insurance Department. See pages 49–50. Ask if they keep a record of complaints against insurance companies, and ask whether these can be shared with you. When deciding which Medigap policy is right for you, consider any complaints against the insurance company. • Call your State Health Insurance Assistance Program. See pages 49–50. These programs can give you free help with choosing a Medigap policy. • Go to your local public library for help with the following: ■
Get information on an insurance company’s financial strength from independent rating services such as The Street.com Ratings, A.M. Best, and Standard & Poor’s.
■
Look at information about the insurance company online.
• Talk to someone you trust, like a family member, your insurance agent, or a friend who has a Medigap policy from the same Medigap insurance company.
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Section 4: Steps to buying a Medigap policy
STEP 3:
Call the insurance companies that sell the Medigap policies you’re interested in and compare costs.
Before you call any insurance companies, figure out if you are in your Medigap open enrollment period or if you have a guaranteed issue right. Read pages 16–17 and 23–26 carefully. If you have questions, call your State Health Insurance Assistance Program. See pages 49–50. The chart below can help you keep track of the information you get. Ask each insurance company…
Company 1 Company 2
“Are you licensed in ___?” [Say the name of your state] Note: If the answer is NO, stop right here, and try another company. “Do you sell Medigap Plan ___?” [Say the letter of the Medigap plan you’re interested in.] Note: Insurance companies usually offer some, but not all, Medigap policies. Make sure the company sells the plan you want. Also, if you’re interested in a Medicare SELECT or high deductible Medigap policy, say so. “Do you use medical underwriting for this Medigap policy?” Note: If the answer is NO, go to step 4. If the answer is YES, but you know you’re in your Medigap open enrollment period or have a guaranteed issue right to buy that Medigap policy, go to step 4. Otherwise, you can ask, “Can you tell me whether I am likely to qualify for the Medigap policy?” “Do you have a waiting period for pre-existing conditions?” Note: If the answer is YES, ask how long the waiting period is, and write it in the box. “Do you price this Medigap policy by using community-rating, issue-age-rating, or attained-age-rating?” See page 19. Note: Circle the one that applies for that insurance company. “I am ___ years old. What would my premium be under this Medigap policy?” Note: If it is attained-age, ask, “How frequently does the premium increase due to my age?” “Has the premium for this Medigap policy increased in the last 3 years due to inflation or other reasons?” Note: If the answer is YES, ask how much it has increased, and write it in the box. “Do you offer any discounts or additional (innovative) benefits?” See page 21. “Is there any extra charge to process my claims automatically?”
Community Issue-age Attained-age
Community Issue-age Attained-age
Section 4: Steps to buying a Medigap policy
31
STEP 3: (continued) Watch out for illegal insurance practices It’s illegal for anyone to do the following: • Pressure you into buying a Medigap policy, or lie to or mislead you to switch from one company or policy to another. • Sell you a second Medigap policy when they know that you already have one, unless you tell the insurance company in writing that you plan to cancel your existing Medigap policy. • Sell you a Medigap policy if they know you have Medicaid, except in certain situations. • Sell you a Medigap policy if they know you are in a Medicare Advantage Plan (like an HMO, PPO, or Private Fee-for-Service Plan) unless your coverage under the Medicare Advantage Plan will end before the effective date of the Medigap policy. • Claim that a Medigap policy is part of the Medicare Program or any other Federal program. Medigap is private health insurance. • Claim that a Medicare Advantage Plan is a Medigap policy. • Sell you a Medigap policy that can’t legally be sold in your state. Check with your State Insurance Department (see pages 49–50) to make sure that the Medigap policy you are interested in can be sold in your state. • Misuse the names, letters, or symbols of the U.S. Department of Health & Human Services (HHS), Social Security Administration (SSA), Centers for Medicare & Medicaid Services (CMS), or any of their various programs like Medicare. (For example, they can’t suggest the Medigap policy has been approved or recommended by the Federal government.) • Claim to be a Medicare representative if they work for a Medigap insurance company. • Sell you a Medicare Advantage Plan when you say you want to stay in Original Medicare and buy a Medigap policy. A Medicare Advantage Plan isn’t the same as Original Medicare. See page 5. If you enroll in a Medicare Advantage Plan, you will be disenrolled from Original Medicare and can’t use a Medigap policy. If you believe that a Federal law has been broken, call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950. Your State Insurance Department can help you with other insurance-related problems.
32
Section 4: Steps to buying a Medigap policy
STEP 4: Buy the Medigap policy. Once you decide on the insurance company and the Medigap policy you want, you should apply and the insurance company must give you a clearly worded summary of your Medigap policy. Read it carefully. If you don’t understand it, ask questions. Remember the following when you buy your Medigap policy: • Filling out your application. Fill out the application carefully and completely. If the insurance agent fills out the application, make sure it’s correct. The answers you give will determine your eligibility for open enrollment or guaranteed issue rights. Answer the medical questions carefully. If you buy a Medigap policy during your Medigap open enrollment period or provide evidence that you’re entitled to a guaranteed issue right, the insurance company can’t use any medical answers you give to deny you a Medigap policy or change the price. The insurance company can’t ask you any questions about your genetic history or require you to take a genetic test. • Paying for your Medigap policy. It’s best to pay for your Medigap policy by check, money order, or bank draft. Make it payable to the insurance company, not the agent. If buying from an agent, get a receipt with the insurance company’s name, address, and telephone number for your records. Some companies may offer electronic funds transfer. • Starting your Medigap policy. Ask for your Medigap policy to become effective when you want coverage to start. Generally, Medigap policies begin the first of the month after you apply. If, for any reason, the insurance company won’t give you the effective date for the month you want, call your State Insurance Department. See pages 49–50. Note: If you already have a Medigap policy, ask for your new Medigap policy to become effective when your old Medigap policy coverage ends. • Getting your Medigap policy. If you don’t get your Medigap policy in 30 days, call your insurance company. If you don’t get your Medigap policy in 60 days, call your State Insurance Department. See pages 49–50. If you already have a Medigap policy, it’s illegal for an insurance company to sell you a second policy unless you tell them in writing that you will cancel the first Medigap policy. However, don’t cancel your old Medigap policy until the new one is in place, and you decide to keep it. See page 34. Once you get the new Medigap policy, you have 30 days to decide if you want to keep the new policy. This is called your “free look” period. The 30-day free look period begins on the day you get your Medigap policy. You will need to pay both premiums for one month.
33
SECTION
5
For people who already have a Medigap policy
You should read this section if any of these situations apply to you: • You’re thinking about switching to a different Medigap policy. See pages 34–37. • You’re losing your Medigap coverage. See page 38. • You have a Medigap policy with Medicare prescription drug coverage. See pages 39–40. (If you just want a refresher about Medigap insurance, turn to page 9.)
34
Section 5: For people who already have a Medigap policy
Switching Medigap policies If you’re satisfied with your current Medigap policy’s cost and coverage and the customer service you get, you don’t need to do anything. If you’re thinking about switching to a new Medigap policy, below and pages 35–37 answer some common questions about switching Medigap policies. Can I switch to a different Medigap policy? In most cases, you won’t have a right under Federal law to switch Medigap policies, unless you are within your 6-month Medigap open enrollment period or are eligible under a specific circumstance for guaranteed issue rights. But, if your state has more generous requirements, or the insurance company is willing to sell you a Medigap policy, make sure you compare benefits and premiums before switching. If you bought your Medigap policy before 1992, it may offer coverage that isn’t available in a newer Medigap policy. On the other hand, older Medigap policies might not be guaranteed renewable and might have bigger premium increases than newer, standardized Medigap policies currently being sold.
Words in blue are defined on pages 51–54.
If you decide to switch, don’t cancel your first Medigap policy until you have decided to keep the second Medigap policy. On the application for the new Medigap policy, you will have to promise that you will cancel your first Medigap policy. You have 30 days to decide if you want to keep the new Medigap policy. This is called your “free look” period. The 30-day free look period starts when you get your new Medigap policy. You will need to pay both premiums for one month.
Section 5: For people who already have a Medigap policy
35
Switching Medigap policies (continued) Do I have to switch Medigap policies if I have an older Medigap policy? No. If you buy a new Medigap policy, you have to give up your old policy (except for your 30-day “free look period,” see page 34). Once you cancel the policy, you can’t get it back, and it can no longer be sold because it isn’t a standardized policy. Do I have to wait a certain length of time after I buy my first Medigap policy before I can switch to a different Medigap policy? No. You should be aware that if you’ve had your old Medigap policy for less than 6 months, the Medigap insurance company may be able to make you wait up to 6 months for coverage of a pre-existing condition. However, if your old Medigap policy had the same benefits, and you had it for 6 months or more, the new insurance company can’t exclude your pre-existing condition. If you’ve had your Medigap policy less than 6 months, the number of months you’ve had your current Medigap policy must be subtracted from the time you must wait before your new Medigap policy covers your pre-existing condition. If the new Medigap policy has a benefit that isn’t in your current Medigap policy, you may still have to wait up to 6 months before that benefit will be covered, regardless of how long you have had your current Medigap policy. If you’ve had your current Medigap policy longer than 6 months and want to replace it with a new one and the insurance company agrees to issue the new policy, they can’t write pre-existing conditions, waiting periods, elimination periods, or probationary periods into the replacement policy.
36
Section 5: For people who already have a Medigap policy
Switching Medigap policies (continued) Why would I want to switch to a different Medigap policy? Some reasons for switching may include the following: • You’re paying for benefits you don’t need. • You need more benefits than you needed before. • Your current Medigap policy has the right benefits, but you want to change your insurance company. • Your current Medigap policy has the right benefits, but you want to find a policy that is less expensive. It’s important to compare the benefits in your current Medigap policy to the benefits listed on pages 11 and 13. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 44–46. To help you compare benefits and decide which Medigap policy you want, follow the “Steps to buying a Medigap policy” on pages 27–32. If you decide to change insurance companies, you can call the new insurance company and arrange to apply for your new Medigap policy. If your application is accepted, call your current insurance company, and ask to have your coverage ended. The insurance company can tell you how to submit a request to end your coverage. As discussed on page 34, you should have your old Medigap policy coverage end after you have the new Medigap policy for 30 days. Remember, this is your 30-day free look period. You will need to pay both premiums for one month.
Section 5: For people who already have a Medigap policy
37
Switching Medigap policies (continued) Can I keep my current Medigap policy (or Medicare SELECT policy) or switch to a different Medigap policy if I move out-of-state? You can keep your current Medigap policy regardless of where you live as long as you still have Original Medicare. If you want to switch to a different Medigap policy, you’ll have to check with the new insurance company to see if they’ll offer you a different Medigap policy. You may have to pay more for your new Medigap policy and answer some medical questions if you’re buying a Medigap policy outside of your Medigap open enrollment period. See pages 16–18. If you have a Medicare SELECT policy and you move out of the policy’s area, you have the following choices: • Buy a standardized Medigap policy from your current Medigap policy insurance company that offers the same or fewer benefits than your current Medicare SELECT policy. If you’ve had your Medicare SELECT policy for more than 6 months, you won’t have to answer any medical questions. • You have a guaranteed issue right to buy Medigap Plan A, B, C, F, K, or L that is sold in most states by any insurance company. What happens to my Medigap policy if I join a Medicare Advantage Plan? Words in blue are defined on pages 51–54.
Medigap policies can’t work with Medicare Advantage Plans. If you decide to keep your Medigap policy, you’ll have to pay your Medigap policy premium, but the Medigap policy can’t pay any deductibles, copayments, coinsurance, or premiums under a Medicare Advantage Plan. So, if you want to join a Medicare Advantage Plan, you may want to drop your Medigap policy. Contact your Medigap Plan insurance company to find out how to disenroll. However, if you leave the Medicare Advantage Plan you might not be able to get the same Medigap policy back, or in some cases, any Medigap policy unless you have a “trial right” (see guaranteed issue right, Situation #4 and #5 on page 25). Your rights to buy a Medigap policy may vary by state. You always have a legal right to keep the Medigap policy after you join a Medicare Advantage Plan.
38
Section 5: For people who already have a Medigap policy
Losing Medigap coverage Can my Medigap insurance company drop me? If you bought your Medigap policy after 1992, in most cases the Medigap insurance company can’t drop you because the Medigap policy is guaranteed renewable. This means your insurance company can’t drop you unless one of the following happens: • You stop paying your premium. • You weren’t truthful on the Medigap policy application. • The insurance company becomes bankrupt or insolvent. However, if you bought your Medigap policy before 1992, it might not be guaranteed renewable. At the time these Medigap policies were sold, state laws might not have required that these Medigap policies be guaranteed renewable. This means the Medigap insurance company can refuse to renew the Medigap policy, as long as it gets the state’s approval to cancel your Medigap policy. However, if this does happen, you have the right to buy another Medigap policy. See the guaranteed issue right, (Situation #6) on page 25.
Medigap policies and Medicare prescription drug coverage If you bought a Medigap policy before January 1, 2006, and it has coverage for prescription drugs, see below and page 39. Medicare offers prescription drug coverage (Part D) for everyone with Medicare. If you have a Medigap policy with prescription drug coverage, that means you chose not to join a Medicare Prescription Drug Plan when you were first eligible. However, you can still join a Medicare Prescription Drug Plan. Your situation may have changed in ways that make a Medicare Prescription Drug Plan fit your needs better than the prescription drug coverage in your Medigap policy. It’s a good idea to review your coverage each fall, because you can join a Medicare Prescription Drug Plan between November 15—December 31 each year. Your new coverage will begin on January 1 of the following year.
Section 5: For people who already have a Medigap policy
39
Medigap policies and Medicare prescription drug coverage (continued) Why would I change my mind and join a Medicare Prescription Drug Plan? In a Medicare Prescription Drug Plan, you may have to pay a monthly premium, but Medicare pays a large part of the cost. There’s no maximum yearly amount. However, a Medicare Prescription Drug Plan might only cover certain prescription drugs (on its “formulary” or “drug list”). It’s important that you check whether your current prescription drugs are on the Medicare Prescription Drug Plan’s list of covered prescription drugs before you join. If your Medigap premium or your prescription drug needs were very low when you had your first chance to join a Medicare Prescription Drug Plan, your Medigap prescription drug coverage may have met your needs. However, if your Medigap premium or the amount of prescription drugs you use has increased recently, a Medicare Prescription Drug Plan might now be a better choice for you. Will I have to pay a late enrollment penalty if I join a Medicare Prescription Drug Plan now? This will depend on whether your Medigap policy includes “creditable prescription drug coverage.” This means that the Medigap policy’s drug coverage pays, on average, at least as much as Medicare’s standard prescription drug coverage. If it isn’t creditable coverage, and you join a Medicare Prescription Drug Plan now, you’ll probably pay a higher premium (a penalty added to your monthly premium) than if you had joined when you were first eligible. You should also consider that your prescription drug needs could increase as you get older. Each month that you wait to join a Medicare Prescription Drug Plan will make your late enrollment penalty higher. Your Medigap carrier must send you a notice every year telling you if the prescription drug coverage in your Medigap policy is creditable. You should keep these notices in case you decide later to join a Medicare Prescription Drug Plan.
40
Section 5: For people who already have a Medigap policy
Medigap policies and Medicare prescription drug coverage (continued) Will I have to pay a late enrollment penalty if I join a Medicare Prescription Drug Plan now? (continued) If your Medigap policy includes creditable coverage and if you decide to join a Medicare Prescription Drug Plan, you won’t have to pay a late enrollment penalty as long as you don’t drop your Medigap policy before you join the Medicare Prescription Drug Plan. You can only join a Medicare Prescription Drug Plan between November 15—December 31 each year unless you lose your Medigap policy (for example, if it isn’t guaranteed renewable, and your company cancels it). In that case, you can join a Medicare Prescription Drug Plan at the time you lose your Medigap policy. Can I join a Medicare Prescription Drug Plan and have a Medigap policy with prescription drug coverage? No. If your Medigap policy covers prescription drugs, you must tell your Medigap insurance company if you join a Medicare Prescription Drug Plan so it can remove the prescription drug coverage from your Medigap policy and adjust your premium to reflect the removal of your Medigap prescription drug coverage. Once the drug coverage is removed, you can’t get that coverage back even though you didn’t change Medigap policies. What if I decide to drop my entire Medigap policy (not just the Medigap prescription drug coverage)? If you decide to drop the entire Medigap policy, you need to be careful about the timing. For example, you may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage), or you might decide to switch to a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. If you drop your entire Medigap policy and the prescription drug coverage wasn’t creditable or you go more than 63 days before your new Medicare coverage begins, you have to pay a late enrollment penalty for your Medicare Prescription Drug Plan, if you choose to join one. You can join a Medicare Prescription Drug Plan or Medicare Advantage Plan between November 15—December 31 each year. Your coverage will begin on January 1 of the following year.
41
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Medigap policies for people with a disability or ESRD
6
Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD) You may have Medicare before 65 due to a disability or ESRD (permanent kidney failure requiring dialysis or a kidney transplant). If you’re a person with Medicare under 65 and have a disability or ESRD, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. These states are listed on the next page. Important: These are the minimum Federal standards. For your state requirements, call your State Health Insurance Assistance Program. See pages 49–50.
42
Section 6: Medigap policies for people with a disability or ESRD
Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD) (continued) At the time of printing this guide, the following states required insurance companies to offer at least one kind of Medigap policy to people with Medicare under 65: • California* • Maryland • Oklahoma • Colorado • Massachusetts* • Oregon • Connecticut • Michigan • Pennsylvania • Delaware** • Minnesota • South Dakota • Florida • Mississippi • Texas • Hawaii • Missouri • Vermont* • Illinois • New Hampshire • Wisconsin • Kansas • New Jersey • Louisiana • New York • Maine • North Carolina * A Medigap policy isn’t available to people with ESRD under 65. ** A Medigap policy is only available to people with ESRD. Even if your state isn’t on the list above, some insurance companies may voluntarily sell Medigap policies to people under 65, although they will probably cost you more than Medigap policies sold to people over 65, and they can use medical underwriting. Check with your state about what rights you might have under state law. Words in blue are defined on pages 51–54.
Remember, if you are already enrolled in Medicare Part B, you will get a Medigap open enrollment period when you turn 65. You will probably have a wider choice of Medigap policies and be able to get a lower premium at that time. During the Medigap open enrollment period, insurance companies can’t refuse to sell you any Medigap policy due to a disability or other health problem, or charge you a higher premium (based on health status) than they charge other people who are 65. Because Medicare (Part A and/or Part B) is creditable coverage, if you had Medicare for more than 6 months before you turned 65, you may not have a pre-existing condition waiting period. For more information about the Medigap open enrollment period and pre-existing conditions, see pages 16–17. If you have questions, call your State Health Insurance Assistance Program. See pages 49–50.
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7
Medigap coverage in Massachusetts, Minnesota, and Wisconsin
Medigap policies for Massachusetts . . . . . . . . . . . . . . . . . 44 Medigap policies for Minnesota . . . . . . . . . . . . . . . . . . . . . 45 Medigap policies for Wisconsin. . . . . . . . . . . . . . . . . . . . . . 46
44
Section 7: Medigap coverage charts
Massachusetts—Chart of standardized Medigap policies Basic benefits included in Medigap policies available in Massachusetts • Inpatient Hospital Care: Covers the Medicare Part A coinsurance plus coverage for 365 additional days after Medicare coverage ends • Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare-approved amount) • Blood: Covers the first 3 pints of blood each year • Part A Hospice coinsurance or copayment The checkmarks in this chart mean the benefit is covered. Medigap Benefits
Basic Benefits
Core Plan
Supplement 1 Plan
✓
✓
Medicare Part A: Inpatient Hospital Deductible
✓
Medicare Part A: Skilled Nursing Facility Coinsurance
✓
Medicare Part B: Deductible
✓
Foreign Travel Emergency
✓
Inpatient Days in Mental Health Hospitals State-Mandated Benefits (Annual Pap tests and mammograms. Check your plan for other state-mandated benefits.)
60 days per calendar year
120 days per benefit year
✓
✓
For more information on these Medigap policies, call your State Insurance Department. See pages 49–50. You can also visit www.medicare.gov, and select “Compare Health Plans and Medigap Policies in Your Area.”
Section 7: Medigap coverage charts
45
Minnesota—Chart of standardized Medigap policies Basic benefits included in Medigap policies available in Minnesota • Inpatient Hospital Care: Covers the Medicare Part A coinsurance • Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare-approved amount) • Blood: Covers the first 3 pints of blood each year • Part A Hospice and respite cost sharing • Parts A and B home health services and supplies cost sharing The checkmarks in this chart mean the benefit is covered. Medigap Benefits Basic Benefits
Basic Plan
✓
Extended Basic Plan
✓
Medicare Part A: Inpatient Hospital Deductible
✓
Medicare Part B: Deductible
✓
✓ ✓ Medicare Part A: Skilled (Provides 100 days of (Provides 120 days of Nursing Facility (SNF) Coinsurance SNF care) SNF care) Foreign Travel Emergency
80%
80%*
Outpatient Mental Health
50%
50% 80%*
Usual and Customary Fees
Mandatory Riders Insurance companies can offer four additional riders that can be added to a Basic Plan. You may choose any one or all of the riders to design a Medigap policy that meets your needs. • Medicare Part A: Inpatient Hospital Deductible
Medicare-covered Preventive Care
✓
✓
Physical Therapy
20%
20%
• Medicare Part B: Deductible
80%*
• Usual and Customary Fees
✓
• Non-Medicare Preventive Care
Coverage while in a Foreign Country State-mandated Benefits (Diabetic equipment and supplies, routine cancer screening, reconstructive surgery, and immunizations)
✓
* Pays 100% after you spend $1,000 in out-of-pocket costs for a calendar year. Minnesota version of Medigap Plans K and L are available, and Minnesota Plans M, N and high deductible F will be offered effective June 1, 2010. Important: The Basic and Extended Basic benefits are available when you enroll in Part B, regardless of age or health problems. If you return to work and drop Part B to elect your employer’s health plan, you will get another 6-month Medigap open enrollment period after you retire from that employer when you can elect Part B again.
46
Section 7: Medigap coverage charts
Wisconsin—Chart of standardized Medigap policies Basic benefits included in Medigap policies available in Wisconsin • Inpatient Hospital Care: Covers the Part A coinsurance • Medical Costs: Covers the Part B coinsurance (generally 20% of the Medicareapproved amount) • Blood: Covers the first 3 pints of blood each year • Part A Hospice coinsurance or copayment The checkmarks in this chart mean the benefit is covered. Medigap Benefits
Basic Plan
Basic Benefits
✓
Medicare Part A: Skilled Nursing Facility Coinsurance
✓
Optional Riders Insurance companies are allowed to offer additional riders to a Medigap policy. • Part A Deductible
Inpatient Mental Health Coverage
175 days per lifetime in addition to Medicare’s benefit
• Additional Home Health Care (365 visits including those paid by Medicare)
Home Health Care
40 visits in addition to those paid by Medicare
• Part B Deductible
Outpatient Mental Health
✓
• Part B Excess Charges • Foreign Travel
For more information on these Medigap policies, call your State Insurance Department. See pages 49–50. You can also visit www.medicare.gov, and select “Compare Health Plans and Medigap Policies in Your Area.” Plans known as “50% and 25% Cost-sharing Plans” are available. These plans are similar to standardized Plans K (50%) and L (25%). A high deductible plan ($1,900 in 2010) also will be available on and after June 1, 2010.
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8
For more information
Where to get more information On pages 49–50, you will find telephone numbers for your State Health Insurance Assistance Program and State Insurance Department. • Call your State Health Insurance Assistance Program for help with any of the following: ■
Buying a Medigap policy or long-term care insurance
■
Dealing with payment denials or appeals
■
Medicare rights and protections
■
Choosing a Medicare plan
■
Deciding whether to suspend your Medigap policy
■
Questions about Medicare bills
• Call your State Insurance Department if you have questions about the Medigap policies sold in your area or any insurance-related problems.
48
Section 8: For more information
How to get help with Medicare and Medigap questions If you have questions about Medicare, Medigap, or need updated telephone numbers for the contacts listed on pages 49–50, you can do the following: Visit www.medicare.gov: • For Medigap policies in your area, select “Compare Health Plans and Medigap Policies in Your Area.” • For updated telephone numbers, select “Find Helpful Phone Numbers and Websites.” Call 1-800-MEDICARE (1-800-633-4227): • Customer service representatives are available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Section 8: For more information
State
State Health Insurance Assistance Program
State Insurance Department
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska
1-800-243-5463 1-800-478-6065 Not Available 1-800-432-4040 1-800-224-6330 1-800-434-0222 1-888-696-7213 1-800-994-9422 1-800-336-9500 1-800-963-5337 1-800-669-8387 1-671-735-7388 1-888-875-9229 1-800-247-4422 1-800-548-9034 1-800-452-4800 1-800-351-4664 1-800-860-5260 1-877-293-7447 1-800-259-5301 1-877-353-3771 1-800-243-3425 1-800-243-4636 1-800-803-7174 1-800-333-2433 1-800-948-3090 1-800-390-3330 1-800-551-3191 1-800-234-7119
1-800-433-3966 1-800-467-8725 1-671-653-1835 1-800-325-2548 1-800-224-6330 1-800-927-4357 1-800-930-3745 1-800-203-3447 1-800-282-8611 1-877-693-5236 1-800-656-2298 1-671-653-1835 1-808-586-2790 1-800-721-3272 1-866-445-5364 1-800-622-4461 1-800-351-4664 1-800-432-2484 1-800-595-6053 1-800-259-5300 1-800-300-5000 1-800-492-6116 1-617-521-7794 1-877-999-6442 1-800-657-3602 1-800-562-2957 1-800-726-7390 1-800-332-6148 1-800-234-7119
49
50
Section 8: For more information
State
State Health Insurance Assistance Program
State Insurance Department
Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands
1-800-307-4444 1-866-634-9412 1-800-792-8820 1-800-432-2080 1-800-701-0501 1-800-443-9354 1-888-575-6611 Not Available
1-800-992-0900 1-800-852-3416 1-800-446-7467 1-800-947-4722 1-800-342-3736 1-800-546-5664 1-800-247-0560 1-670-664-3064
1-800-686-1578 1-800-763-2828 1-800-722-4134 1-800-783-7067 1-877-725-4300 1-401-462-4444 1-800-868-9095 1-800-536-8197 1-877-801-0044 1-800-252-9240 1-800-541-7735 1-800-642-5119 1-340-772-7368 1-340-714-4354 (St.Thomas) 1-804-662-9333 1-800-562-6900 1-202-739-0668 1-877-987-4463 1-800-242-1060 1-800-856-4398
1-800-686-1526 1-800-522-0071 1-888-877-4894 1-877-881-6388 1-888-304-8686 1-401-222-2223 1-800-768-3467 1-800-310-6560 1-800-342-4029 1-800-252-3439 1-866-350-6242 1-800-631-7788 1-340-774-7166
Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
1-877-310-6560 1-800-562-6900 1-202-727-8000 1-888-879-9842 1-800-236-8517 1-800-438-5768
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9
Definitions
Coinsurance—An amount you may be required to pay as your share of the costs for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment—An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription. Deductible—The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Excess Charge—If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicareapproved amount, the difference is called the excess charge.
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Section 9: Definitions
Guaranteed Issue Rights (also called “Medigap Protections”)—Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem. Guaranteed Renewable—An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable. Medicaid—A joint Federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medical Underwriting—The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.
Medicare Advantage Plan (Part C)—A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. Medicare-approved Amount—In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges. Medicare Cost Plan—A type of Medicare health plan. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
Section 9: Definitions Medicare Health Maintenance Organization (HMO) Plan—A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician. Medicare Medical Savings Account (MSA) Plan—MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins. Medicare Preferred Provider Organization (PPO) Plan—A type of Medicare Advantage Plan (Part C) available in some areas of the country in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
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Medicare Prescription Drug Plan (Part D)— A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare PrivateFee-for-Service Plans, and Medicare Medical Savings Account Plans. If you have a Medigap policy without prescription drug coverage, you can also add a Medicare Prescription Drug Plan. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Medicare Private Fee-for-Service (PFFS) Plan—A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you receive care. A Private Fee-for-Service Plan is very different than Original Medicare, and you must follow the plan rules carefully when you go for health care services. When you’re in a Private Fee-for-Service Plan, you may pay more, or less, for Medicare-covered benefits than in Original Medicare. Medicare SELECT—A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.
54
Section 9: Definitions
Medicare Special Needs Plan (SNP)—A special type of Medicare Advantage Plan (Part C) 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. Open Enrollment Period (Medigap)—A one-time-only, 6-month period when Federal law allows you to buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law. See pages 16–17. Original Medicare—Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits. Pre-existing Condition—A health problem you had before the date that a new insurance policy starts. Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage. State Health Insurance Assistance Program (SHIP)—A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
State Insurance Department—A state agency that regulates insurance and can provide information about Medigap policies and other private insurance.
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SECTION
List of topics
10
A At-home Recovery ................................................................................... 11, 13 Attained-age-rated Policies.............................................................. 19–20, 30 B Blood ..............................................................................................11, 13, 44–46 C Changing (Switching) Medigap Policies .............................................. 34–37 Claim Filing .......................................................................................................... 22 COBRA (Consolidated Omnibus Budget Reconciliation Act) ................... 24 Coinsurance............................................................... 2, 3, 5–6, 11–13, 44–46, 51 Comparing Cost ............................................................................................. 21 Copayment ........................................................... 2, 3, 5–6, 11–13, 44–46, 51 Creditable Coverage ............................................................................... 39–40 D Deductible ................................................................. 3, 5–6, 11–13, 44–46, 51 Disability.................................................................................................... 41–42
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Section 10: List of topics
E Employer Group Health Plan....................................................................... 24 End-Stage Renal Disease (ESRD) ..................................................... 4, 41–42 Excess Charges............................................................................. 11, 13, 46, 51 F Finding Reliable Insurance Companies ...................................................... 29 Foreign Travel Emergency.................................................. 11, 13, 21, 44–46 G Guaranteed Issue Rights ..........................................15, 17, 21, 23–26, 30, 52 Guaranteed Renewable ............................................................... 15, 34, 38, 52 H Health Maintenance Organization (HMO) Plan ............ 4–6, 9, 14, 31, 53 High-deductible Option ................................................................... 11, 13, 21 Hospice Care ............................................................................ 4, 11–13, 44–46 I Illegal Insurance Practices ................................................................. 6, 15, 31 Inspector General’s Office ............................................................................ 31 Issue-age-rated Policies .................................................................... 19–20, 30 L Long-term Care Insurance ............................................................................ 47 M Medicaid ...................................................................................3, 14, 26, 31, 52 Medical Savings Account Plan ................................................................. 6, 53 Medical Underwriting ............................................. 16, 18–19, 21, 30, 42, 52 Medicare Advantage Plan...................... 4–6, 9, 14–15, 24–25, 31, 37, 40, 52 Medicare-approved Amount ....................................................... 9, 44–46, 52 Medicare Cost Plan ................................................................................ 5–6, 52 Medicare Part A (Hospital Insurance)........... 2, 4–5, 11–13, 15, 22, 44–46 Medicare Part B (Medical Insurance) ............ 2, 4–5, 11–13, 18, 22, 44–46 Medicare Prescription Drug Plan ................... 2, 4–7, 12, 14, 16, 38–40, 53 Medicare SELECT .......................................... 9, 10, 12, 22, 24–26, 30, 37, 53 Medicare Supplement Insurance ............................................ (see Medigap)
Section 10: List of topics
57
M (continued) Medigap Best Time To Buy ............................................................................... 16–17 Claim Filing................................................................................................ 22 Steps To Buying .................................................................................. 27–32 Under 65 .............................................................................................. 41–42 What It Is ................................................................................................. 3, 9 What’s Covered and What’s Not Covered ..................................... 10–14 Medigap Benefits Chart Plans A through N ............................................................................. 11, 13 Massachusetts ............................................................................................ 44 Minnesota ................................................................................................... 45 Wisconsin ................................................................................................... 46 Medigap Policies and Medicare Prescription Drug Coverage .......... 39–40 Medigap Protections (Guaranteed Issue Rights)................................. 23–26 Moving ....................................................................................................... 24, 37 N No-age-rated Policies ..................................................................................... 19 O Open Enrollment Period (Medigap) ... 15–18, 23, 30, 32, 34, 37, 42, 45, 54 Original Medicare .......................................................... 4–7, 9–10, 24–25, 54 P PACE (Programs of All-Inclusive Care for the Elderly) ............... 5, 25–26 Pre-existing Condition .............................................16–17, 23, 30, 35, 42, 54 Preferred Provider Organization (PPO) Plan .........................................6, 53 Premium ....................................................2, 12, 15, 19–21, 30, 34, 37–39, 54 Prescription Drug Coverage (Medicare) ........................... 2, 4–7, 16, 38–40 Preventive Care .................................................................................. 11, 13, 45 Pricing Policies ......................................................................................... 19–20 Private Fee-for-Service Plan ......................................................... 6, 14, 31, 53 R Reliability ......................................................................................................... 29 Right to Buy a Medigap Policy............................................................... 23–26
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Section 10: List of topics
S Skilled Nursing Facility (Care) ...................................................11, 13, 44–46 Special Needs Plan ..................................................................................... 6, 54 State Health Insurance Assistance Program........................ 26, 47, 49–50, 54 State Insurance Department .................................................26, 47, 49–50, 54 Switching Medigap Policies .................................................................... 34–37 T TRICARE ......................................................................................................... 14 U Union Coverage .............................................................................................. 14 V Veterans’ Benefits............................................................................................ 14 W Waiting Period .............................................................................16–17, 30, 42 www.medicare.gov ......................................................................... 7, 16, 28, 48
Section 10: List of Topics
Notes
Use this page to write down important notes or phone numbers.
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60
Section 10: List of Topics
Notes
Use this page to write down important notes or phone numbers.
Important Information about this Guide The information, telephone numbers, and web addresses in this guide were correct at the time of printing. Changes may occur after printing. To get the most up-to-date information and Medicare telephone numbers, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. The “2010 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 Official Business Penalty for Private Use, $300 CMS Product No. 02110 Revised March 2010
To get this publication on audiotape, in Braille, large print (English), or Spanish, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. ¿Necesita una copia en español? Visite www.medicare.gov en el sitio Web. Para saber si esta publicación esta impresa y disponible (en español), llame GRATIS al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048.
Emergency Respite Care
Issue Date: August
2000
NC Health Choice for Children
EMERGENCY RESPITE CARE Information for Children with Special Needs and Their Parents Introduction Like all families, those who have children with special health care needs want the best possible health care for their children. For families with children with special health care needs, this may require many trips to the doctor or specialist, coordination of special therapies or medications, and constant care at home. The responsibility of having a child with special needs can sometimes become overwhelming. It may not be as easy for these families to find someone to care for their child when an emergency comes up. This is where emergency respite care under Health Choice can help. Children with special health care needs enrolled in NC Health Choice for Children may be eligible to receive emergency respite care. This benefit is designed to allow families to respond when they have an emergency they need to attend to. Parents may use emergency respite care to take care of unexpected personal matters such as a medical emergency or death in the family, or an unplanned situation in which parents are temporarily unable to care for their child. We suggest that you read this booklet carefully, perhaps several times. You will then be more familiar with emergency respite care and how it might be helpful to your family. You may want to bring this booklet with you to share with your respite care provider so that you both understand what emergency respite care is and how it works under NC Health Choice for Children. This booklet has been organized into three sections: ! ! !
Answers to Frequently Asked Questions Ideas for Making Things Work, and Important Addresses and Phone Numbers 1
ANSWERS TO FREQUENTLY ASKED QUESTIONS How do I know if my child has a special need? A child may have a special need if a medical, behavioral, developmental, or mental condition or a problem with alcohol or drug abuse is expected to last six (6) months or more. To find out if your child has a special need, answer the following questions. 1. Is it harder for your child to breathe, eat, dress, bathe, go to the bathroom, talk, or learn than for other children his or her age? 2. Have you been told that your child has a long-lasting (chronic) health or mental health condition? 3. Have you been told that your child has a delay in mental, emotional, physical, or social development? 4. Does your child need special services, special equipment, or drugs for medical, behavioral, or other health conditions? 5. Does your child use or need any developmental disability, mental health, alcohol, or drug services? If you answered yes to any of these questions, your child may be able to receive additional medical or mental health care through NC Health Choice.
Only children with special health care needs are eligible to receive emergency respite care under Health Choice. 2
What is emergency respite care? During emergency respite care, a respite care provider will temporarily take over your responsibilities as caregiver. The person usually responsible for caring for the child with special needs is free for a short period of time. Emergency respite care can be provided in one of three ways. ! ! !
A provider you have selected may come into your home, or Your child may go to the home of a respite care provider, or Your child may go to center-based emergency respite care.
Under NC Health Choice, emergency respite care may be provided for unplanned situations in which family members temporarily do not have the capacity to safely care for their child or when changes in their child’s health, behavior, or development require in-home or out-ofhome temporary support. Circumstances that would be considered emergency include, but are not limited to the following: ✦
✦ ✦
An unplanned situation in which the child temporarily lacks supervision or shelter (such as homelessness), A medical emergency in the family, and A death in the family.
This means that emergency respite care cannot be used for planned vacations, or to run errands. It must only be used during emergency situations.
3
How do I get approval for emergency respite care under Health Choice? If you think your family is likely to benefit from this service, you must prepare before you need emergency respite care!
There are several steps you must take to make sure you will be able to get emergency respite care when an emergency arises. 1. First, your child’s medical provider should sign and mail in the Special Needs (SN) form certifying that your child meets the Health Choice definition of ‘child with special needs’. (See page 16 for a copy of the form.) 2. Second, if your family feels that you are likely to benefit from emergency respite care you should locate a respite care provider in your community that is able to meet your needs. (See ‘How do I find a Respite Care Provider’ on page 5.) 3. Lastly, your family should contact the NC Health Choice Emergency Respite Care Case Manager at 1-800-753-3224 between the hours of 8:30 a.m. to 5:00 p.m. to register the child *. The Case Manager will enter basic information about your child (name, Health Choice ID number, address, phone number, respite care provider agency) into the client database to make the approval process at the time of the emergency go more quickly.
Once you’ve completed steps one, two, and three, your child will be registered for emergency respite care.
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4. When emergency respite care is needed, your family or respite care provider should contact the Case Manager at 1-800-753-3224 to receive pre-approval. This line is available 24 hours a day, 365 days a year. The Case Manager will review the child’s and family’s situation and will consider a number of factors, including the impact the child’s condition has on a parent’s ability to cope and on their ability to provide care. The Case Manager will consider the appropriateness of the service request and treatment plan and will determine approval for emergency respite care as appropriate.
How do I find a Respite Care Provider? You may call our Special Needs Helpline, 1-800-737-3028 anytime between 8:00 a.m. and 5:00 p.m. Monday through Friday to get the names and phone numbers of respite care providers in your area.
5
How do I choose the right respite care provider for my family? Respite care agencies vary from community to community. It will be important to talk with the provider you select about your child’s needs and about the services the agency will provide. Make sure the provider will be able to provide the level of care that your child requires. Make sure that you understand what areas you will be responsible for (i.e. stocking up on necessary food and medical supplies). Make sure that you know how to contact the agency when you have an emergency. Find out how quickly they will be able to respond in an emergency situation.
How long will emergency respite care be provided? Each request for emergency respite care will be reviewed individually. Therefore, there is no set number of hours that can be authorized. The Case Manager will review the child’s and family’s situation and will approve enough emergency respite care for each situation.
How much emergency respite care can I get in a year? Remember that Health Choice only covers emergency respite care. There is no set number of respite hours per year. Each request for emergency respite care is reviewed individually. Requests for emergency respite care during a true emergency will not be denied just because you have already used emergency respite care during the year.
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What do I do when there is an emergency and I need emergency respite care? When emergency respite care is needed, the family or provider should contact the Case Manager at 1-800-753-3224 to receive approval. This line is available 24 hours a day, 365 days a year. The Case Manager will review the child’s and family’s situation and will consider a number of factors, including the impact the child’s condition has on a parent’s ability to cope and on their ability to provide care. The Case Manager will consider the appropriateness of the service request and treatment plan and will provide approval for emergency respite care as appropriate.
What do I do if I request emergency respite care and my request is denied? If you call to request emergency respite care and your request is denied by the Case Manager, you may ask to speak with the Supervisor. He or she will ask for additional information about your situation and will make a decision regarding your request for emergency respite care.
How will our emergency respite provider be paid? The respite care provider agency will keep track of the hours of emergency respite care provided to your family. Health Choice will reimburse the agency for the approved time. There is no cost to you and no co-payment required for emergency respite care.
7
How do we enforce family “rules”? In order for the respite experience to be a smooth and pleasant one for the entire family, consideration needs to be given to the establishment of “house rules” regarding the home, the child, and the parents themselves. You should communicate your ‘house rules’ to the respite care provider before an emergency occurs. You may want to keep this information in a written care plan, so that a new provider coming into the home will know what is expected. (See page 12 for a sample care plan.) Here are some items to consider:
8
Respite Worker
✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦
Parking Access to family home Storage of personal belongings Meals Smoking Television/radio Telephone Visitors
Child
✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦
Parents
✦ Communication with respite worker ✦ Privacy
Home
✦ Areas off-limits to pets
Routines, nap time Mealtime/snacks Selection of clothing Discipline issues Homework Chores of child Areas off-limits to play Acceptable outside play areas Names of friends who can visit Amount of television viewing (hours per day and acceptable shows) ✦ Number of telephone calls and length
How do we know if the emergency respite care my child receives is good? Agencies that provide respite care should have guidelines for the provision of services to families of children with disabilities or chronic illnesses. Guidelines for care delivery, along with minimum qualifications for respite workers, help to ensure that children are receiving high quality care. If you have questions or if the emergency respite care your child receives is not what you expected, talk with the respite care provider agency. Be specific in addressing what you expect from the respite worker and make sure this information is included in your care plan. The care plan can be changed at any time. If the agency cannot meet the needs of your child, you may want to consider changing respite care provider agencies. Call the Health Choice Special Needs Helpline at 1-800-737-3028 for help identifying respite care provider agencies in your area.
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TIPS FOR MAKING THINGS WORK 1. Establish a care plan for your child. Include information about the medications they receive, any allergies they have, their likes and dislikes, and anything else that would help someone else care for your child. Keep one copy of the plan on file with your respite care provider agency and keep another copy at home. Make sure to update the plan as changes occur. 2. Keep a list of important phone numbers handy. Include ✦ The Health Choice Case Manager, 1-800-753-3224 ✦ The Respite Care Provider Agency ✦ Your child’s medical provider 3. If your child needs special food or medical supplies, be sure to keep enough on hand to last if an emergency should occur. 4. Keep the lines of communication between your family and the respite care provider agency open. Keep them informed of major changes in your child’s condition and keep your care plan updated. Let the agency know when their service has been especially helpful. This will make it easier to talk about areas you want them to work on.
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IMPORTANT TELEPHONE NUMBERS Registration and Approval for Emergency Respite Care 1-800-753-3224 1-919-941-1007 (fax) To help with your questions about emergency respite care or other benefits for children with special needs under NC Health Choice, a tollfree Helpline is available Monday-Friday from 8:00 a.m. to 5:00 p.m.
NC Health Choice Helpline 1-800-737-3028 Information you share will remain confidential just as anything you share with your health care provider would be.
11
NC Health Choice for Children Sample Care Plan
INFORMATION FOR EMERGENCY RESPITE CARE WORKERS Child’s Name
Age
Address
Phone number Name and phone of family doctor Hospital name and phone number Poison Control phone number Phone number where the parents can be reached Cell phone or pager number(s) for parents Any allergies or special medical information for children
12
TIPS FOR TAKING CARE OF MY CHILD ❖ What is special about my child:
❖ My child’s schedule: MORNING
AFTERNOON
EVENING
FEEDING ✦ Meal times Breakfast
Lunch
Dinner
✦ Special Instructions
13
SLEEP HABITS AND NAP TIME
❖ Likes and dislikes:
✦ Play activities ✦ Favorite/Special toys Inside areas off-limits to play Acceptable outside play areas Acceptable visitors/playmates ❖ Special things that comfort my child:
❖ Handling Special instructions for bath time Transporting ❖ Discipline ❖ Special equipment ❖ Communication strategies ❖ Things to think about when selecting and adapting new activities:
14
WHAT IS EXPECTED FROM THE RESPITE WORKER DURING EMERGENCY RESPITE CARE 1. Meal preparation and feeding 2. Cleanup (e.g. meal and snack, toy pickup, etc.)
3. Supervision of my child 4. Visitors: It is / visitors while I am gone.
is not all right to have
5. Telephone use: It is / is not all right to use the telephone, other than for emergencies, while I am gone. Other Important House Rules:
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NC Health Choice for Children
ELIGIBILITY FOR EMERGENCY RESPITE CARE Purpose: To be eligible for Emergency Respite Care under NC Health Choice for children, a child must meet the legislative definition of ‘child with special needs’. The purpose of this form is to assist in the determination that a child meets the clinical criteria so that he or she may be registered as eligible for emergency respite care.
Child’s Name:
DOB:
Child’s SS#: Parent/Guardian Name: Address: Phone Number: Name of Physician providing information: Please Print
I confirm that the above-named child has been diagnosed with: In my opinion, this diagnosis meets the criteria of at least one of the following categories: (check all that apply)
! ! ! !
Birth Defect (including genetic, congenital or acquired disorders) Developmental Disability Mental or Behavioral Disorder Chronic or Complex Illness
In my opinion, this (these) condition(s) will: (all must be checked for eligibility to be approved)
! ! ! !
Continue Indefinitely Interfere with Daily Routine Require Extensive Medical Intervention and Extensive Family Management
Physician’s signature:
Date:
Phone Number: Mail to: Case Manager, PO Box 12438, RTP, NC 27709-2438 16
North Carolina Department of Health and Human Services Division of Public Health • Women's and Children's Health Section A. Dennis McBride, MD, MPH, State Health Director
The NC Department of Health and Human Services does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. 1,500 copies of this public document were printed at a cost of $537.65 or $.36 per copy. 08/00
17
NC Health Choice Handbook
NC Health Choice Handbook 2006 2008 - 2007
2006 - 2007 2008
1. Choose a doctor. Be sure he or she accepts NC Health Choice.
2. Make an appointment for a check-up. Get to know your child’s doctor and staff. When your child gets sick, you’ll have a trusted Medical Home you can turn to!
Make the MOST of your NC Health Choice benefits in 5 easy steps... Medicaid Eligibility Unit Division of Medical Assistance 2501 Mail Service Center Raleigh, NC 27669-2501
3. Call the doctor anytime you have questions about your child’s health. But especially before going to the emergency room!
4. Read this handbook. You’ll find loads of information on benefits and resources.
ADDRESS SERVICE REQUESTED
5. Re-enroll next year!
Re-enrollment packages packages come come in in the the mail, mail, so Re-enrollment so let let the the DSS DSS know know ifif you move! move! Remember, Remember, you a year keep you you must must re-enroll re-enroll once to keep yourto child’s yourHealth child’s NC Health Choice coverage! NC Choice coverage!
L1280 11/08– PLEASE – PLEASE NOT DESTROY. REMAINS EFFECTIVE UNTIL HANDBOOK IS PRINTED. L1280 3/06 DODO NOT DESTROY. REMAINS EFFECTIVE UNTIL NEWNEW HANDBOOK IS PRINTED
Table Of Contents
Table Of Contents.......................................................................................1 Welcome To NC Health Choice For Children..............................................3 Privacy........................................................................................................4 Identification (ID) Cards ..............................................................................5 Make The Most Of Your NC Health Choice Benefits...................................6 Coverage At A Glance ................................................................................7 Copays .....................................................................................................10 Children With Special Health Care Needs ................................................11 Going To A Health Care Professional .......................................................12 Going To The Doctor For Wellness Check-ups.........................................13 Going To The Dentist................................................................................13 Going For A Hearing Exam .......................................................................16 Going For An Eye Exam ...........................................................................17 Treatment Outside North Carolina ............................................................17 Treatment Outside The USA.....................................................................18 When You Buy Medical Supplies ..............................................................19 Going To The Hospital ..............................................................................20 If Your Child Needs Short-Term Rehabilitation For Medical Reasons .......21 If Your Child Needs Surgery .....................................................................21 Getting Prior Approval Before Starting Certain Services or Getting Equipment ................................................................................................22 Getting Prior Approval Before Surgery......................................................24 Medical Care With Limits ..........................................................................25 Care That Is Not Covered .........................................................................27 Going To The Doctor or Counselor For Mental Health, Alcohol or Drug Treatment .................................................................................................31 How To File a Claim..................................................................................34 What Happens After Your Claim Is Processed?........................................35 If You Have Questions About Your Child’s Benefits or Claims ..................35 Fraud ........................................................................................................36 Medical Appeals .......................................................................................37 Mental Health, Alcohol and Drug Treatment Appeals................................39 Commonly Used Terms ............................................................................40 Important Telephone Numbers and Addresses.........................................43
1
2
Welcome To NC Health Choice For Children NC Health Choice, the State of North Carolina Children’s Health Insurance Program, is a program funded by the federal and state governments. NC Health Choice may be stopped or suspended at any time if federal or state money is no longer available. A child who lives in the state of North Carolina, is age 6 through 18 and has no health insurance may be covered depending on the family’s income. Departments of social services in each county in the state determine if a child qualifies for coverage under NC Health Choice. To apply for coverage or to ask questions about enrolling or re-enrolling your child, please contact your county department of social services. The telephone number should be in your telephone book under “County Government.” You may also call the NC Family Health Resource Line at 1-800-367-2229 for general information about NC Health Choice and to find out the location and phone number of your local department of social services. Information about the program is found in the North Carolina General Statutes. If any information in this handbook conflicts with the General Statutes and/or the Medical Policy adopted by the North Carolina State Health Plan for Teachers and State Employees Board of Trustees, the General Statutes and/or the Medical Policy will prevail. Please read this handbook carefully so that you will understand the benefits. If you have questions, ask your child’s doctor, county department of social services or county health department for help. You may also call Customer Service at 1-800-422-4658. Additional information: •
The NC Healthy Start Foundation’s “Child Health Insurance” for the public Web site at: www.NCHealthyStart.org
•
The NC Health Choice section of the Department of Health and Human Services (DHHS) Web site at: www.dhhs.state.nc.us/dma/cpcont.htm
•
Link to the NC Health Choice Law: http://www.dhhs.state.nc.us/dma/CHIP/nchc2000law.pdf
•
Link to the County Department of Social Services Directory: www.dhhs.state.nc.us/dss/local/index.htm
•
The North Carolina State Health Plan for Teachers and State Employees’ Web site is www.shpnc.org.
Member Services Member Services provides safe access to information online. You can check claim status and order ID cards online. Go to www.shpnc.org and register for Member Services.
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Privacy NC Health Choice respects your right to privacy. If you want someone to help you with questions about your child’s coverage, such as a friend, doctor, or someone at the department of social services or at the county health department, you must fill out and sign a Member / Dependent Authorization Request form. NC Health Choice uses the release form to make sure that confidential information is given only to authorized people. Confidential information includes medical treatment, whether a claim has been filed or paid or other information about your child. When calling, you will be asked questions that will help us to confirm who you are and to protect your child’s privacy. Custodial and non-custodial parents are allowed to receive the same information about a child. If you have a custodial agreement, please provide legal documentation that includes the custodial parent’s name and address. You may get a Member / Dependent Authorization Request form for: •
Physical Health: Call Customer Service at 1-800-422-4658, or you may download a form from the State Health Plan Web site at www.shpnc.org. Click Important Forms then under NC Health Choice forms, click on ‘Authorize a Representative.’
•
Mental Health: Call the Mental Health Case Manager at 1-800-753-3224. You and your child will need to sign a special consent form if you wish to give permission for the NC Health Choice Mental Health Case Manager to release your personal information.
To complete the Member / Dependent Authorization Request form: • • • •
Give the name of the person who is allowed to help you. Include the ID number of your child. Sign the form. Mail the form to Customer Service. (See address on page 35.)
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Identification (ID) Cards
You will receive one (1) identification (ID) card in the mail for each child enrolled in NC Health Choice. You should always show the ID card when you take your child to a doctor, clinic, hospital or other health care professional for medical care or to the drug store when you buy a prescription drug. If more than one child is covered, please make sure you take the right ID card with you. The ID card may show that you have a $5 office / outpatient copay, a $1, $3, or $10 prescription drug copay, and a $20 emergency room copay. This means that you have to pay the first few dollars of a charge when you take your child to the doctor’s office, outpatient therapist for counseling, hospital for outpatient care, emergency room or pharmacy.
If you do not show your child’s ID card, the person treating your child may not know that he or she is covered under NC Health Choice. You may then be charged for the full cost of treatment or prescription drug. If the ID card is lost and you need to get a new one, you may call Customer Services at 1-800-422-4658 or request one online through Member Services at www.shpnc.org.
The front of the ID card has important information such as your child’s: name date of birth ID number effective date (date coverage begins) copay information
• • • • •
CHILDREN’S HEALTH INSURANCE PLAN Rx BIN # 610014 Rx GRP # NCSHPHC
Name Doe, John Date of Birth 12/09/1989 I.D. Number YPP W12-XX-XXXX-X-X
Claims Processing Contractor
PO Box 30111 Durham, NC 27702-3111
Office/Outpatient Copay Drug Copay Emergency Room
CHILDREN’S HEALTH INSURANCE PLAN Rx BIN # 610014 Rx GRP # NCSHPHC
Name Doe, John Date of Birth 12/09/1989 I.D. Number YPP W12-XX-XXXX-X-X
Claims Processing Contractor
PO Box 30111 Durham, NC 27702-3111
Office/Outpatient Copay Drug Copay Emergency Room
$0.00 $0.00 $0.00
Effective Date 10/01/1999
Send Claims other than for Prescription Drugs to: Claims Processing Contractor PO Box 30025 • Durham, NC 27702-3025
NC Health Choice (NCHC) is administered by Blue Cross and Blue Shield of North Carolina (BCBSNC), an independent licensee of the Blue Cross and Blue Shield Association. BCBSNC does not set benefits or rates or assume any financial risk for NCHC. No network access is available from Blue Cross and Blue Shield Plans outside of NC.
If your child’s ID card shows $0 for certain copays, you do not have to help pay for that type of covered medical care.
$0.00 $0.00 $0.00
Copays must be paid to the doctor, pharmacy, or hospital when the service is provided for your child.
Effective Date 10/01/1999
Send Claims other than for Prescription Drugs to: Claims Processing Contractor PO Box 30025 • Durham, NC 27702-3025
NC Health Choice (NCHC) is administered by Blue Cross and Blue Shield of North Carolina (BCBSNC), an independent licensee of the Blue Cross and Blue Shield Association. BCBSNC does not set benefits or rates or assume any financial risk for NCHC. No network access is available from Blue Cross and Blue Shield Plans outside of NC.
• Eligibility should be verified prior to providing services. • For further information refer to your NC Health Choice Handbook or call Customer Services at 1-800-422-4658.
The back of the ID card has important phone numbers to call before your child is admitted to the hospital for medical care or receives mental health, alcohol or drug treatment.
• Mental Health and Chemical Dependency Services must be precertified by calling 1-800-753-3224, 24 hours a day, 7 days a week. • Hospital Admissions other than for mental health or chemical dependency must be precertified by calling 1-800-672-7897, M - F, 8 a.m. to 5 p.m., (after hours leave message). • Physicians and other medical providers should file claims to the local Blue Cross and/or Blue Shield plan where services are rendered. • Pharmacy Customer Service: 1-800-336-5933 • Pharmacy Services Help Desk: 1-800-922-1557
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Make The Most Of Your NC Health Choice Benefits Step 1: Choose a doctor. Find a doctor that you and your child like. If you need help finding a doctor, call Customer Service at 1-800-422-4658 or your caseworker at the local department of social services. If you already have a doctor, be sure he or she takes NC Health Choice. Step 2: Make an appointment. Bring your child in for a well child check-up. That way problems can be identified early before they become bigger problems. Going for well child check-ups helps the staff get to know you, your child, and your child’s health history. They will also make sure that your child continues to get all needed shots (immunizations) on time. When your child gets sick, you’ll already have a trusted Medical Home you can turn to. Step 3: Call the doctor anytime. Call whenever you have questions about your child’s health, but especially before going to the emergency room. Take along this handbook and the ID card when you receive any service for your child. This will help you and your doctor make the right decisions for your child. Step 4: Read this handbook. Inside you’ll find loads of information on benefits and resources. Learn all you can about your child’s health and what kind of doctors, drugs, therapists, equipment or supplies may be needed. Keep your handbook and all of your child’s medical information in one place. Step 5: Re-enroll next year. Children on NC Health Choice need to re-enroll once a year. Look for your Reenrollment Package in the mail. Be sure to let the local department of social services (DSS) know if you move or you will not receive this important mailing. Re-enroll quickly so that your child’s coverage will continue uninterrupted.
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Coverage At A Glance This is only a summary of your child’s benefits. Although care may be listed as being covered, the care must be medically necessary and there may be limits. These limits can mean that only part of the service is covered. You may also need to get approval before getting certain types of care. You are responsible for reading this handbook and knowing your child’s coverage. If you have questions, call Customer Service at 1-800-422-4658. Coverage
Explanation
Copay
You may have to pay the first few dollars of a charge: • $5 office / outpatient copay (includes hearing, vision, mental health and chemical dependency) • $1, $3, or $10 prescription drug copay • $20 ER (emergency room) copay Some families only have prescription drug copays. Look at your child’s ID card to see which copays apply to you. Note: There are no copays for well child check-ups, ageappropriate immunization services or routine dental check-ups.
Doctor Care • Office visits
See Page (s) 5, 10, 12-13, 15-20, 25, 31, 34-35, 40-41 10, 18, 19 10, 19 18 5
Covered. (May have a $5 office / outpatient copay.)
13
•
Wellness check-ups
Covered as follows: o yearly physical exams (once every 365 days) o routine shots (immunizations)
13
•
Surgery
Covered. Some surgeries need prior approval.
15, 23
•
Inpatient care
Covered.
20
Covered. (May have drug copay of $1, $3 or $10.) Some prescription drugs require prior approval. If you have a question about whether a drug may require prior approval, you may call the Pharmacy Benefit Manager, Medco, at 1-800-366-5933.
5, 10, 18, 20, 28, 34, 35, 40, 41, 42
Covered. (May have a $20 emergency room copay.)
5, 6, 10, 19
Prescription Drugs
Medical or Surgical Hospital Care • Emergency room •
Outpatient
Covered. Some surgeries need prior approval.
•
Inpatient
Covered. Needs preadmission certification and length-of-stay approval before being admitted.
7
19, 22, 24 20
Coverage
Outpatient Surgery Ambulance Service X-ray, Lab and Radiation Therapy Therapy Services
Durable Medical Equipment Home Care Home Nursing Care
Mental Health, Alcohol and Drug Treatment
Explanation
See Page (s)
Covered. Some surgeries need prior approval. Needs approval for land transport over 50 miles and for all air ambulance. See additional information under the section, “Medical Care with Limits” Covered.
19, 21, 24 25
Covered. (May have a $5 office / outpatient copay.) Physical, occupational and respiratory therapies need prior approval when given in the home. Speech therapy needs prior approval when given in the home or office. Covered. Must be medically necessary and a covered item. Needs prior approval for all purchases, rentals and repairs over $1,000. Covered when medically necessary for skilled care. Some limits apply. Needs prior approval. Covered. Limited to skilled nursing visits, home care aides under the direct supervision of a registered nurse (RN) and private duty nursing. Needs prior approval. There are also other limitations (See additional information under the section, “Medical Care with Limits.”)
10, 12, 19
19, 20
23 26 26
•
Outpatient treatment
Covered. (May have a $5 office / outpatient copay.) Up to 26 outpatient visits covered in a Plan Year without getting prior approval. Over 26 visits in a Plan Year (July 1 – June 30) covered only if approved in advance by the Mental Health Case Manager. See covered providers on page 32.
31, 32
•
Treatment in higher levels of care
Covered. Inpatient and partial hospitalization, residential treatment, and care in a structured / intensive outpatient program. Preadmission certification for non-emergency admissions is required from the Mental Health Case Manager before being admitted to any of these types of care.
32, 33
Covered for routine cleaning, polishing, exams and fluoride treatments once every 6 months, sealants for children ages 6 through 15 years old, silver and tooth colored fillings, simple tooth pulling only (pulling impacted teeth or wisdom teeth is not covered), pulpotomy and stainless steel crowns. Effective, July, 1, 2009, space maintainers and root canals st on permanent front teeth and permanent 1 molars are covered.
13, 14
Dental Care • Diagnostic services and preventive maintenance
•
Oral surgery
Covered. Needs prior approval.
15, 23, 24
•
Accidental injury
Covered if your child is covered on the date of the accident. Needs prior approval. Repairs the mouth and teeth to the way they were before the accident
14
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Coverage TMJ
(temporomandibular joint dysfunction)
Treatment
Organ Transplants Hearing Care Vision Care
Explanation
See Page (s)
Covered. (May have a $5 office / outpatient copay.) Limited to office visits and tests to diagnose TMJ. Splint therapy and surgery are covered only after an accident when your child was covered on the date of the accident and treatment began within 18 months following the accident.
15, 16
Surgery and splint therapy need prior approval. Covered. Corneal, bone marrow, kidney, liver, heart, lung, heartlung and pancreas are covered. Cannot be experimental or investigational. Needs prior approval. Covered. (May have a $5 office / outpatient copay.) Services may include exams, hearing aides, repairs, ear molds, loaners and rentals. Needs prior approval. Covered. (May have a $5 office / outpatient copay.)
16, 22, 24 24, 26 16, 23, 24
•
Eye exam
Covered. Once every 12 months.
17
•
Lenses
Covered. Only one set of glasses or contacts every 12 months.
17
•
Frames
Covered. Only one set of frames every 24 months.
17
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Copays Some children enrolled in NC Health Choice have office / outpatient visit, emergency room and prescription drug copays. This means that you have to pay the first few dollars of a charge when you take your child to a doctor or therapist, to the hospital for outpatient care, to the emergency room, or when you buy a prescription drug. You can find your copay requirements on your child’s NC Health Choice ID card. Your card may show a copay for prescription drugs, doctor or other outpatient therapist, outpatient hospital visit, or emergency room (ER) visit. If the ID card says there is $0 copay for a specific service, then you pay nothing for that service. If you have questions about copays, take this handbook to your child’s doctor or pharmacist and ask him or her to help you. You may also call Customer Service at 1-800-422-4658. You will get more information about brand and generic drugs under the, “When You Buy A Prescription Drug” section of this handbook. Copay $1.00
Type of Covered Prescription Drug Each covered brand drug without a generic substitute available
$1.00
Each covered generic drug
$3.00 or $10.00 Each covered brand drug with a generic substitute available Copay $0 $5.00
Type of Covered Service There is no copay for wellness check-ups, age-appropriate immunization services or preventative dental services. Each visit to any doctor’s office or to any outpatient therapist.
$5.00
Each outpatient hospital visit
$20.00
Each emergency room (ER) visit
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Children With Special Health Care Needs Additional Benefits for Children with Special Health Care Needs: Most children will be able to get all the services they need under the core (basic) plan of NC Health Choice. The core plan is outlined in this handbook. Children who need services that are not covered by the core plan may qualify for additional coverage. This additional coverage is called the Special Needs Plan. There is a separate booklet that explains the Special Needs Plan. No separate application process or enrollment fee is required to qualify. You do not have to pick one plan over the other. A child with special needs will have access to both plans while enrolled in NC Health Choice. To learn more about the Special Needs Plan, call the Children With Special Health Care Needs Help Line at 1-800-737-3028. Ask for a Special Needs Booklet, which is a companion piece to this NC Health Choice Benefits Handbook. A child with special needs is defined as a child with conditions or problems that: • • •
have lasted or are expected to last for twelve months or more; and, interfere with the child’s daily routine; and, require more medical care and family management than most children need.
Your child’s doctor must certify that your child qualifies for the Special Needs Plan. To do so, the doctor completes a Physician Certification form that asks about birth defects, mental or behavioral disorders, long-term or complicated illnesses, acquired illnesses or disorders, or developmental disabilities. The Physician Certification form: •
may be sent to NC Health Choice by any doctor caring for a child who meets the special needs definition above, or
•
may be completed by the doctor at the request of NC Health Choice when a prior approval request or claim has been submitted for services above the core plan and a certification form is not yet on file with NC Health Choice.
You or your child’s doctor can obtain a Physician Certification form by calling the Children with Special Health Care Needs Help Line at 1-800-737-3028.
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Going To A Health Care Professional When your child sees the doctor in an office, urgent care center, hospital outpatient clinic, or in your home, please show your ID card. If the ID card says there is a $5 office / outpatient copay, you should pay that at the time of the visit. Besides doctors’ services, the copay is required for physical, speech, occupational and inhalation therapies, for chiropractic visits and for IV (intravenous) therapy. The copay does not apply to injected medications, laboratory, pathology and radiology. You may take your child to any of the health care professionals listed below who are licensed in the State of North Carolina. The type of care and treatment that these professionals give must also be covered under NC Health Choice in order for them to be paid by the Plan. If your child gets treatment that is not covered by NC Health Choice, you must pay the entire bill. (see pages 27 through 30) This is a list of health care professionals whose care or treatment is covered by NC Health Choice. The type of care and treatment provided must also be covered and within the scope of the health professional’s license in order for the service to be eligible for benefits. If you have questions, call Customer Service at 1-800-422-4658. Doctor of medicine (MD) Doctor of osteopathy (DO) Doctor of podiatry (DPM) Doctor of chiropractic (DC) Doctor of dental surgery (DDS) or (DMD) Licensed physician assistant (PA) Licensed physical, speech, respiratory and occupational therapists Nurse (some advanced practice registered nurses, registered nurses and licensed practical nurses) Home care aide (under the direct supervision of a registered nurse and employed by a licensed home care agency) This is a list of health care professionals whose care or treatment is not covered by NC Health Choice. If you have questions, call Customer Service at 1-800-422-4658. • • • • • •
(This list is not all-inclusive.) Person not licensed to practice in North Carolina (or not licensed in the state in which service is rendered) Doctor of holistic / naturopathic medicine Homeopath Acupuncturist Doctor of Chinese / Oriental Medicine Massage therapist
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Your child can also get medical care if a licensed MD (medical doctor) or DO (doctor of osteopathy) either oversees or provides the care at any of the following: county health departments rural community health centers migrant health centers Indian health centers Covered mental health, drug and alcohol treatment professionals are located on page 32. Going To The Doctor For Wellness Check-ups NC Health Choice covers routine wellness check-ups and screening tests to find out the health of your child. Routine wellness check-ups can include such things as an exam by the doctor and blood, urine and TB (tuberculosis) tests. These wellness check-ups are done when your child is either healthy or not showing any symptoms or problems. NC Health Choice pays for wellness check-ups including yearly physical exams (once every 365 days). NC Health Choice pays for routine shots (immunizations) to prevent such diseases as measles or mumps. You do not have to pay an office visit copay for these routine wellness check-ups and there is also no copay for routine immunizations. NC Health Choice does not cover routine check-ups, tests or reports that are needed for such things as school, camp, legal, employment, insurance, sports or travel. A visit to the doctor when your child is sick is different from taking your child to the doctor for a wellness check-up. There is no limit on the number of visits to the doctor when your child is sick. Going To The Dentist NC Health Choice covers two (2) routine dental check-ups during the 12-month period that your child is enrolled. You should schedule these visits once every six (6) months to make sure that your child’s teeth stay healthy. You do not have to pay an office visit copay for routine dental check-ups. As part of these routine dental check-ups, NC Health Choice covers: exams (limited to two within 12 months) cleanings and polishing (limited to two within 12 months) fluoride treatments (limited to two within 12 months) 13
NC Health Choice covers x-rays of the teeth: back teeth limited to once every 12 months and entire mouth limited to once every 5 years NC Health Choice also covers: sealants for children ages 6 through 15 years old for 1st and 2nd molars and 1st and 2nd permanent premolars only silver and tooth colored fillings Pulpotomy (removing part of the nerve in a tooth) stainless-steel crowns minor treatment of dental pain simple extractions Effective, July 1, 2009, NC Health Choice will cover: extractions other than impacted teeth or wisdom teeth space maintainers root canal therapy on permanent front teeth and permanent 1st molars NC Health Choice does not cover the following: • pulling impacted teeth or wisdom teeth • repositioning impacted teeth to help them erupt into the mouth • sedative, or temporary fillings • braces • retainers or other dental appliances (including gold and tooth colored crowns, bridges, inlays, veneers or partial and full dentures) • dental implants • root canals on baby teeth, premolars or 2nd & 3rd molars • treatment of gum disease • rebuilding gums before getting an appliance • rebuilding the bone before getting an appliance • anesthesia reported as a separate charge / service (Note: Anesthesia given in the office is not eligible for separate reimbursement. If billed separately, you are responsible.) • incidental services that are considered part of the primary dental service
Accident-Related Dental Care NC Health Choice covers repair of your child’s mouth or teeth following an accidental injury (such as injury from a fall) when your child is covered under NC Health Choice on the day that an accident happens and initial treatment is sought within a reasonable period of time (typically within 48 hours). Dental care is covered to repair your child’s mouth or teeth as they were before the accident. All accident related dental care must be completed within a reasonable period of time (typically 18 months) following the accident and before your child’s coverage ends. 14
When you take your child to the dentist, please take your child’s ID card with you. If the ID card says that there is a $5 office visit / outpatient copay, you should pay that to the dentist at the time of the visit. Note: You do not have to pay a copay for preventative dental check-ups. The following are some dental services after accidents that are not covered: • Replacement of a dental appliance that can be fixed when broken in an accident. • Improvements to the teeth. • Dental services that are needed because of a chewing or eating accident. • Dental care (due to decay) that would have been needed even if an accident had not happened. • Dental treatment recommended prior to your child’s enrollment in NC Health Choice. • Dental services that are needed because of an accident that occurred when your child was not covered under NC Health Choice.
Oral Surgery NC Health Choice covers some types of oral surgery for your child. You must get prior approval before your child has oral surgery. (see pages 22 through 24) The following types of oral surgery are covered when approved: Surgical removal of tumors and lesions in the mouth unrelated to the teeth. Surgical correction of jaw and bone conditions that your child is born with (congenital). Surgical correction of the jaw that becomes noticeable as your child grows (developmental) and the condition produces a medical problem (such as problems with speech or nutrition). Surgical removal of teeth because they are damaged as the direct result of medical treatment such as chemotherapy. The following are some oral surgeries that are not covered: • Surgery to correct the alignment of teeth. • Surgery to replace missing teeth with dental implants, bridges, partial or full dentures. • Surgical removal of impacted teeth or wisdom teeth • Dental services that are needed because of a chewing or eating accident • Removal of cysts when other dental procedures are done, including extractions.
Temporomandibular Joint Dysfunction (TMJ) Temporomandibular joint dysfunction (TMJ) is the medical term used to describe problems with the jaw joint (clicking and pain when opening or closing the mouth.) If your child experiences these symptoms, you should take your child to a doctor or dentist to find out if she or he has TMJ dysfunction.
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When you take your child to the doctor, please take your child’s ID card with you. If the ID card says there is a $5 office / outpatient copay, you should pay that to the dentist at the time of the visit. NC Health Choice covers the following treatment for TMJ dysfunction: Office visits and tests to find out if your child has TMJ dysfunction. Physical therapy by a qualified medical professional. Splint therapy after an accident when your child is covered under NC Health Choice on the date of the accident. All accident related treatment must be completed within a reasonable period of time (typically 18 months) following the accident and before your child’s coverage ends. Prior approval is required for Splint therapy and TMJ surgery. (see pages 22 through 24) If you have questions about any dental service or treatment for TMJ dysfunction or prior approval, take this handbook to your child’s doctor or dentist and ask him or her to help you. You may also call Member Health Partnerships Operations (MHPO) at 1-800-672-7897 for help. Going For A Hearing Exam NC Health Choice covers routine hearing exams to find out if your child has a hearing loss. Your child must see a licensed audiologist or an ear, nose and throat (ENT) doctor. If your child needs a hearing aid, you must get prior approval before buying it and you must buy it from a licensed hearing aid specialist. (see pages 22 through 24) When you take your child to the doctor or audiologist for a hearing exam, please take your child’s ID card with you. If the ID card says that there is a $5 office / outpatient visit copay, you should pay that at the time of the visit. NC Health Choice covers the following items when they are medically necessary. You must get approval before buying them: Hearing aids Repairs Ear Molds Loaners Rentals Note: Hearing aids must be fully approved by the Food and Drug Administration (FDA). If you have questions about getting a hearing aid for your child, take this handbook to your child’s doctor or audiologist and ask him or her to help you. You may also call Customer Service at 1-800-422-4658.
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Going For An Eye Exam NC Health Choice covers routine eye exams to find out if your child’s vision requires correction. Your child must go to an eye doctor who is a licensed ophthalmologist or optometrist. If your child needs glasses, contact lenses, contact lens solution or supplies, you must also buy them from a certified optical dispensing lab. When you take your child to the eye doctor, please take your child’s ID card with you. If the ID card says that there is a $5 office / outpatient copay, you should pay that at the time of the visit. NC Health Choice covers one (1) eye exam every 12 months. The following services are also covered: 1 set of lenses (either glasses or contacts) every 12 months 1 set of frames every 24 months The exception is if the lenses or frames are broken, the doctor must state that the lenses and / or frames cannot be fixed before approval is given for another pair. NC Health Choice does not cover the following: • • • •
radial keratotomy (RK), LASIK or other procedures to correct vision in place of glasses or contacts sunglasses orthoptics or visual training cost of oversized lenses or frames, designer or deluxe frames, tinted glasses or contacts, blended, coated or laminated lenses
Treatment Outside North Carolina If your child gets medical care or supplies outside of North Carolina, the requirements in this Handbook as well as the following conditions must be met: • •
A licensed doctor, eligible professional or hospital must give the medical care. (see page 12) Ask the doctor to send the claim for the bill to NC Health Choice through their local Blue Cross and Blue Shield plan. (see page 34)
Payment is made to the doctor unless the claim comes in with proof that the family has already paid.
17
Treatment Outside The USA If your child gets medical care, prescription drugs or supplies outside the United States, the following conditions must be met: • • • • •
The care that your child gets outside the USA must have full and unrestricted approval in the USA to be covered by NC Health Choice. A government-licensed doctor, medical professional or hospital must give the medical care. You must pay the bill. You must send the claim for the bill to NC Health Choice. (see page 34) The charge must be translated into English (you have to send the original charge with the claim.)
NC Health Choice does not cover the cost of translating bills. Payment is based on the exchange rate in effect on the day services are received for foreign claims. Payment is sent to you. When You Buy A Prescription Drug NC Health Choice covers prescription drugs and insulin that you buy for your child from a drug store or mail order drug company. A prescription drug is covered if it can only be bought with a doctor’s written prescription. A Pharmacy Benefit Manager (PBM) manages the prescription drug benefit. Medco is the current PBM. When you buy a prescription drug for your child, please have your child’s ID card with you. If the ID card indicates a drug copay, you should pay that to the pharmacist. If you do not show your child’s ID card, the pharmacist may not know that NC Health Choice covers your child. You may then be charged the full cost of the prescription drug. Note: If your child is given drugs while a patient in the hospital, you do not have to pay a copay. The cost of the drugs is part of the hospital bill. Some prescription drugs are limited or require prior approval. Some are not covered. For questions related to prescription drug benefits or filing claims, please contact the PBM at 1-800-336-5933.
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When You Buy Medical Supplies NC Health Choice covers some medical supplies (such as insulin needles, diabetic testing supplies, catheters and tracheostomy supplies). There is not a copay for covered medical supplies. For questions about medical supplies, please contact Customer Service at 1-800-422-4658. Going To The ER (emergency room) NC Health Choice covers your child’s visit to the ER (emergency room) when there is a true emergency. Please take your child’s ID card with you. If the ID cards says that there is a $20 emergency room copay, you should pay that at the time of the visit. If your child is admitted to the hospital or if there is a true emergency, you may not have to pay the $20 emergency room copay. What is an emergency? North Carolina Law defines an emergency as:
Medical: A sudden and unexpected condition requiring urgent medical attention.
Examples of emergencies include: life-threatening problems like choking, bleeding that will not stop or broken bones.
Mental Health / Chemical Dependency: A sudden and unexpected condition of
such severity that your child could immediately injure himself or herself or other people unless there is immediate hospitalization. If your child has a minor problem such as an earache, headache or cold, call your child’s doctor if you are not sure if your child needs to go to the ER. If your child’s doctor is not available, seek medical attention from another physician before going to the ER. If your child goes to the emergency room for a minor problem and the ID card says there is a copay, you will have to pay the $20 emergency room copay. Going To The Hospital, But Not Being Admitted (outpatient) NC Health Choice pays charges for such things as a doctor’s visit, lab work, x-rays, therapy, and covered surgery when your child goes to the hospital or ambulatory surgical facility without being admitted (outpatient). When it is necessary for treatment
19
to be received in an outpatient setting because of a child’s young age or an existing medical condition that will not allow them to be safely treated in the office, NC Health Choice may cover hospital charges, including anesthesia administered by an anesthesiologist. To find out if coverage is available for the outpatient setting and the anesthesiologist, you should have the doctor submit a request for approval. Otherwise, you may have to pay the entire cost. When you take your child to the hospital as an outpatient (not being admitted to stay overnight) or to an ambulatory surgical facility, please take your child’s ID card with you. If the ID card says that there is a $5 office / outpatient copay (and the doctor charges for an office visit), you should pay at the time of the visit. If the ID card says that there is a $0 office / outpatient copay, then you pay nothing. When you buy prescription drugs at the hospital pharmacy to take home, and you have a drug copay, you should pay that to the pharmacist. If you have questions about hospital or ambulatory surgical facility benefits please call Customer Service at 1-800-422-4658. Going To The Hospital NC Health Choice covers many services for your child’s stay in the hospital. Testing before your child is admitted to the hospital is covered if done within 14 days before the admission date. Hospital coverage includes room and board, hospital staff services, and supplies used while in the hospital. NC Health Choice does not cover such things as TV or beauty shop fees. Drugs that your child may need while in the hospital are also covered; you do not have to pay drug copays. These drug charges are part of the hospital bill. Before your child is admitted to the hospital for inpatient care, you must make sure that NC Health Choice gives you preadmission certification and length-of-stay approval. This is done to make sure that a hospital is the best place for your child to get treatment. To do this, the doctor or hospital should call the Member Health Partnerships Operations (MHPO) department at 1-800-672-7897 before your child is admitted to the hospital for medical treatment. Hospital employees must also contact the Member Health Partnerships Operations (MHPO) department when your child’s stay is expected to go beyond the first approval time. They must provide more information as to why a lengthier stay is needed. The Member Health Partnerships Operations (MHPO) staff will give decisions within three (3) business days after getting all the needed information.
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If your child is admitted to the hospital in an emergency during the weekend, holiday or after regular business hours, the doctor or hospital has 48 hours or until the next work day to get preadmission certification and length-of-stay approval. Hospital admissions for mental health, alcohol and drug treatment also require preadmission certification and length-of-stay approval. (See pages 31 through 33 for telephone number and procedure.) If Your Child Needs Short-Term Rehabilitation For Medical Reasons Rehabilitation facility employees are responsible for contacting the Member Health Partnerships Operations (MHPO) staff prior to admission for approval. When a stay is expected to go beyond the initial approval period, the Member Health Partnerships Operations (MHPO) staff will contact the facility to get more information to see if a lengthier stay can be approved. The Member Health Partnerships Operations (MHPO) staff will give approval decisions within three (3) business days after getting all the needed information. If Your Child Needs Surgery NC Health Choice covers most kinds of surgery that your child may need. This includes: Doctor’s charges. Visits before and after the surgery. Assistant surgeons (when necessary). Anesthesia received in a hospital setting. If your child needs surgery, please keep in mind the following: •
Some surgeries may require that you or your child’s doctor get prior approval. (see page 24)
•
If your child is admitted to the hospital, you or your child’s doctor will need to get preadmission certification and length-of-stay approval. (see page 20)
•
The surgery must be covered and considered medically necessary by NC Health Choice
•
The surgery cannot be cosmetic (to improve appearance).
•
The surgery cannot be experimental or investigational.
If you have questions about any surgery, take this handbook to your child’s doctor and ask him or her to help you. You may also call Member Health Partnerships Operations (MHPO) at 1-800-672-7897 for help.
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Getting Prior Approval Before Starting Certain Services or Getting Equipment NC Health Choice offers limited coverage for certain services and medical equipment as long as you or your child’s doctor first gets prior approval. If prior approval is needed, be sure to check with your child’s doctor to make sure prior approval has been received. If you do not get approval when required, you may have to pay the entire cost. Medical records and a letter from the doctor stating why your child needs any of the services, procedures or medical equipment listed on pages 23-24 should be sent to the following address: NC Health Choice Member Health Partnerships Operations (MHPO) Department P O Box 30111 Durham NC 27702-3111 Fax 1-919-765-4890 Phone 1-800-672-7897 The Member Health Partnerships Operations (MHPO) staff will give prior approval decisions within three (3) business days after getting all needed information. Please note: If your child needs services that require prior approval in an emergency on weekends, at night or during holidays, please ask your child’s doctor to request prior approval the next workday. If your child receives covered medical services and you or your child’s doctor did not get prior approval, NC Health Choice will review the coverage of these health care services. This is called a retrospective review. NC Health Choice will make all retrospective review decisions within thirty (30) days after getting all needed information. The Member Health Partnerships Operations (MHPO) staff will give you and your child’s doctor the decision. In order to be considered for retrospective review, NC Health Choice must get requests within six months (180 days) of the last date of service. Requests received after 180 days of the last date of service will not be approved, even if the services were medically necessary. If you have questions about anything needing prior approval, take this handbook to your child’s doctor and ask him or her to help you. You may also call Member Health Partnerships Operations (MHPO) at 1-800-672-7897 for help.
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Services and Equipment - You or your child’s doctor must ask for approval before
your child gets the following services or equipment: Private duty nursing Skilled nursing visits
Home care aides (must be directly supervised by a registered nurse (RN) and employed by a licensed home care agency) Skilled nursing facility care Speech therapy (unless given while in the hospital) Hospice Care Home IV (intravenous) Therapy Physical and occupational therapies (given in the home) Some surgeries (see page 24) Oral surgery and treatment of TMJ dysfunction Licensed ambulance over 50 miles Air ambulance Hearing aids, repairs, ear molds, loaners and rentals Buying, renting, or repairing durable medical equipment if it costs over $1,000 (must be medically necessary and normally used in a hospital) Services provided in the home or in a skilled nursing facility are for short-term skilled care to medically stabilize your child. All services have limitations and approval is based on your child’s medical condition.
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Getting Prior Approval Before Surgery NC Health Choice covers many surgeries for your child. Prior approval is needed before your child has any of the surgeries listed below. If you do not get prior approval when required, you may have to pay the entire cost. Description Plastic surgery to the stomach (abdomen)
Surgery Abdominoplasty
Removing skin over the eye to help a person see better
Blepharoplasty
Inserting a hearing device to help with hearing
Cochlear Implant
Removing large breasts in males
Excision of gynecomastia
Corrective surgery to fallopian tubes
Fimbrioplasty
Stomach or intestinal surgery for morbid obesity to help reduce weight Correction when both ovaries and testicles are present
Gastric surgery Hermaphroditism surgery
Removing scar tissue
Keloid excision
Surgery to the nose to help a person breathe
Nasal surgery
Dental care or surgery to treat an injury
Oral surgery
Surgery to correct a condition of the jaw determined congenital or developmental in nature Reducing the size of breasts in females
Orthognathic surgery
Injecting filling material into the skin
Subcutaneous injection
Removing fat deposits by suctioning
Suction lipectomy
Correction of TMJ with splint or surgery
TMJ surgery
Taking the organ or tissue of one person and surgically implanting into another. Must be a covered transplant. Repairing fallopian tubes
Transplant
Surgery (including injections) to treat varicose veins
Varicose vein surgery
Reduction mammoplasty
Tubotubal anastomosis
If you have questions about anything needing prior approval, take this handbook to your child’s doctor and ask him or her to help you. You may also call Member Health Partnerships Operations (MHPO) at 1-800-672-7897 for help.
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Medical Care With Limits NC Health Choice covers the following medical care with some limits for your child. This is only a partial list.
Acupuncture
Must be provided by an MD (medical doctor) or a DO (doctor of osteopathy) and is only covered for treatment of nausea associated with surgery or chemotherapy.
Ambulance Transportation
Licensed air ambulance requires prior approval Licensed land ambulance transportation is covered in the following situations: •
50 miles or less and one of the following: to or from a hospital for inpatient care or outpatient emergency care from a hospital to the nearest facility which is prepared to accept your child and is able to provide needed services not available at the first hospital from a hospital to a skilled nursing facility
•
50 or more miles requires prior approval.
The following is not covered: Non-emergent transport to or from home, skilled nursing facility or alternate care facility to an outpatient setting. (For example: renal dialysis).
Cardiac rehabilitation programs
Coverage limited to $1,800 or 90 days each Plan year. Must be medically necessary and started within 6 months of your child’s heart illness. Program must be provided in a medically supervised facility certified by the NC Department of Health and Human Services.
Chiropractic care
Limited to $2,000 each Plan year for covered services, which are limited to alignment of the spine, release of pressure by manipulation and X-rays of the spine. Chiropractors are not eligible to provide medications, drugs or nutritional supplements. If foot orthotics or other appliances are needed, they must be purchased from an appliance supplier. Unless your child’s card shows no copay, there is a $5 copay for each visit.
Diabetic self-care programs
Limited to $300 each Plan year. Limited to diabetic counseling and instruction at a medically supervised facility. Must meet the standards of the National Diabetes Advisory Board.
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Home care
Must be homebound or a child with special needs for care in the home to be covered. For home nursing care (skilled nursing visits and private duty nursing), the child’s condition must require care from a licensed nurse for an unstable medical condition. Benefits for private duty nursing are limited to twelve hours per day for children on ventilators and to four hours per day for other children.
Home health care aide services
Coverage is limited to four hours per day. The home health aide must be under the supervision of a licensed health care professional and employed by a licensed home care agency. Only home health aide services that are an extension of skilled services are eligible for coverage (for example, assisting a nurse with wound care). Assisting with bathing, feeding, taking medications and other personal care is not covered.
Therapeutic shoes
Coverage is limited to $350 and to one pair every year. May be covered for conditions such as diabetes or peripheral vascular disease.
Transplant
Requires prior approval for the following covered transplants: corneal, bone marrow, kidney, liver, heart, lung, heart-lung, and pancreas. NC Health Choice will not cover transplants that are experimental or investigational. If you have questions about medical care with limits, take this handbook to your child’s doctor and ask him or her to help you. You may also call Customer Service at 1-800-422-4658 for help.
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Care That Is Not Covered NC Health Choice only covers standard services or treatments commonly recommended for a specific condition. If your child chooses a service that is not standard, you are responsible for the difference in the cost. NC Health Choice does not cover the following services, equipment or supplies for your child (see list below). If your child gets any of these services, equipment or supplies, you must pay for the entire cost. If a service, equipment or supply is not listed on pages 27 through 30, do not assume that it is covered. This is only a partial list. If you have a child with special health care needs, some services, equipment or supplies that are not typically covered by this plan may be covered. See “Children with Special Health Care Needs” section of this handbook (page 11).
Non-covered Services (this is partial list): •
Taxi, bus, gasoline or other personal transportation costs
•
Any services received prior to the effective date of your child’s coverage or after your child’s coverage ends
•
Treatment of disease / injury as a result of military service or a declared or undeclared war
•
Services that are not medically necessary
•
Care related to conditions or treatment not covered by NC Health Choice
•
Experimental / investigational procedures and any direct or indirect complications
•
Surgical / medical procedures specifically listed by the American Medical Association or the North Carolina Medical Society as having questionable or no medical value.
•
Nonskilled services
•
Custodial care
•
Drugs or devices not given unrestricted market approval by the FDA (Food and Drug Administration)
•
Care provided by an ineligible provider
•
Services provided in a facility not appropriately licensed or accredited
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•
Dental implants, dentures, crowns, bridges, onlays, inlays, braces and / or pulling impacted teeth and / or repositioning impacted teeth (Note: Dentures, crowns and bridges can be covered if accident-related)
•
Braces and orthodontics for TMJ (even in the presence of an accident)
•
Dental services that are the result of an accident that occurred while your child was eating or drinking
•
Anesthesia administered by the doctor in an office setting
•
Dental services that are the result of an accidental injury that occurred prior to members coverage effective date
•
Telephone consultations or services
•
Durable Medical Equipment (DME) set up and dispensing fees
•
Charges for services related to on-the-job injuries
•
Care provided by more than one doctor for the same condition on the same day
•
Assistant surgeon when there is no medical necessity or if there are hospitalemployed surgeons or doctors in training available but not used
•
Cosmetic services / surgery and complications from previous cosmetic surgery
•
Health club memberships
•
Vitamins, food supplements or replacements, nutritional supplements, formulas or special foods of any kind unless they require a physician’s prescription to purchase and are for the treatment of certain medical conditions.
•
Radial keratotomy or other procedures to correct vision in place of corrective lenses
•
Orthoptics or visual training exercises
•
Maternity care or any other services related to pregnancy, whether the mother keeps the baby or not
•
Sterilization or reversal of sterilization
•
Sex change surgery and related services and complications
•
Personal services (telephone, TV, laundry, hairdresser, etc.)
•
Administrative costs including writing and getting together reports
•
Complications from non-covered services
•
Sperm analysis and storage
•
Egg Harvesting and storage
See pages 31 through 33 for a list of mental health or alcohol / drug treatment services which are non-covered or which have limits. 28
If you have questions about anything that is not covered, take this handbook to your child’s doctor and ask him or her to help you. You may also call Customer Service at 1-800-422-4658 for help. If your child needs a service that is not listed as a covered service in this handbook, call the Children with Special Health Care Needs Help Line at 1-800-737-3028 to see if it can be covered under the Special Needs Plan.
Non-covered Equipment and Supplies NC Health Choice does not provide benefits for certain supplies and equipment. You are responsible for the cost of these non-covered items or services if you choose to purchase them. NC Health Choice does not cover the delivery and/or set up for equipment considered part of rental or purchase allowance that is billed separately. Do not assume that an item, service or procedure is covered if it is not listed in this Handbook. Contact Customer Service at 1-800-422-4658 if you have questions. If your child has special health care needs, call the Children with Special Health Care Needs Help Line at 1-800-737-3028.
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Non-covered Equipment and Supplies (This is a partial list) Air conditioners, air filtration systems, air cleaners and filters Bed, residential-type Bed board Bath, including jacuzzi, sauna, sitz, whirlpool, and tub and shower accessories (including bath chair systems) Chairs, including recliner, "Roll-away," and Auto-tilt Clothing Computers Humidifiers, dehumidifiers, and vaporizers
Elevator Heat lamps Intercoms (communicators) Mattress (except with hospital bed) Medical alert equipment/services Scales (food or weight) Telephone Alert System Vacuum cleaners
Exercise, sports and massage equipment, (regardless of the reason) including exercise bicycle, gravity inversion equipment, muscle stimulator/massager, treadmill exerciser, weights, weight bench, swimming pool, parallel bars, massage devices and vibration unit Safety equipment, including restraints (padding) and grab bars, (including bathroom rails) Sick room supplies, including bed bath, pillows (cervical or lumbar), emesis basin, heating pad, ice blanket, lambs wool pad, lap tray, surgical face mask and table Wheelchair accessories, including basket/tote bag, beverage holder, bumper wheels, curb ramp, curb ramp holder, custom handle, lap tray, lift (van), lifting handle, power seat lift, ramps and structural modifications, luggage rack and auto wheelchair carrier Youth equipment, including adaptive clothing, air mat, balls, beams, blocks, bolster, classroom aids, cognitive or developmental supplies, crawling aids, cylinders, feeding utensils, grooming supplies, ramps, swings, tables, toys (adaptive/educational) and Tyke-Hike Youth seating equipment, including car seat, classroom chair, high chair (feeder chair), infant relaxers, pony seats, stools and straddle chairs Bath, paraffin Fracture cast sock Biomechanical orthotic device Hand controls, automobile Blood pressure cuff/kit, Hydrocollator Cast impressions Molded shoe Cranial prosthesis (wig) Neuro aides/pads Cryo cuff/cold therapy Nightguards or athletic mouthguards Dentures (unless due to accident) Orthotic stabilizers Diathermy machine Postural drainage board Electrostatic machine Pre-set Portable Oxygen Center Electrical continence aid Rectal dilator Electrocardiocorder Speech teaching machines Extend-A-Hand Spinal-pelvic stabilizers Fiberglass stabilizers Temporomandibular joint appliance (unless due to accident)
If you have questions about anything that is not covered, take this handbook to your child’s doctor and ask him or her to help you. You may also call Customer Service at 1-800-422-4658 for help.
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Going To The Doctor or Counselor For Mental Health, Alcohol or Drug Treatment When you take your child to the doctor or counselor, please take your child’s ID card with you. If the ID card shows a $5 office / outpatient copay, you should pay that amount at the time of the visit. If the ID card shows a $0 office / outpatient copay, then you pay nothing.
Outpatient Visits – If your child needs outpatient visits for mental health, alcohol or
drug treatment:
1. Choose one of the types of doctors or counselors listed on page 32 of this handbook. The doctor or counselor may work in a private office, in a local mental health center, or in some other setting. 2. No preauthorization is required for the first 26 combined visits for mental health and alcohol or drug treatment beginning July 1st of each year. The 26 visits are the total visits for mental health and alcohol or drug treatment. You do not receive 26 visits for mental health and another 26 visits for alcohol and drug treatment. If your child is already getting treatment when he or she enrolls, make sure that your child’s type of doctor or counselor is listed on page 32. 3. If your child is expected to need 27 or more visits during the Plan year (July 1 through June 30), you or your child’s doctor or counselor must call the Mental Health Case Manager at the 18th visit to request an Outpatient Request Form 2 (ORF2) if your doctor or counselor does not already have one. To get this form, call the Mental Health Case Manager at 1-800-753-3224. 4. The Mental Health Case Manager must receive the completed Outpatient Request Form 2 prior to visit 27. If you have concerns about your child’s mental or emotional health and he or she is not currently receiving treatment, NC Health Choice offers six (6) outpatient visits per year for assessment and early intervention. You may take your child to an eligible doctor or counselor to evaluate if he or she is at risk of developing a mental health, alcohol or drug problem. In addition to evaluation, your child may receive individual and group counseling sessions. Ask your child’s doctor or counselor to call the Mental Health Case Manager to ask about special claims filing requirements prior to filing a claim for these services. The Mental Health Case Manager may be reached at 1-800-753-3224. When you call this number, please request to speak with someone in the Account Services Department for NC Health Choice.
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•
The evaluation and counseling must not total more than six visits each year from July 1 through June 30. These visits will count toward the 26 combined visits that do not require preauthorization (see #2 above).
•
Providers of these six visits must have the same credentials as currently required by the Plan for outpatient therapy. (see below)
•
Providers may see your child in a school-based health center, health department, private office, outpatient clinic, or some other setting.
•
Other than these six visits, a mental illness or alcohol / drug diagnosis is required for payment.
The following professionals can provide mental health as well as alcohol and drug treatment services covered by NC Health Choice. If you are seeking services for your child, please make sure care is given by a professional listed below. Licensed psychiatrist (MD) or (DO) Licensed psychologist (PhD), (EdD) or (PsyD) Certified clinical social worker (CCSW) Licensed clinical social worker (LCSW) Licensed professional counselor (LPC) Licensed marriage and family therapist (LMFT) Certified fee-based pastoral counselor (PhD) Licensed psychological associate (LPA) Licensed physician assistant; must be supervised and employed by a psychiatrist Certified clinical specialist in psychiatric and mental health nursing (RN, certified by the American Nurses Credentialing Committee which now certifies clinical specialists as Advanced Practice Registered Nurses, Board Certified) Registered nurse (RN) or (RN-C); must be supervised and employed by a licensed psychiatrist or licensed psychologist The following list may only provide care for alcohol and drug treatment. Certified substance abuse counselor (CSAC) Physician (MD) or (DO) licensed as an MD or DO in the state in which services are provided and be certified by the American Society of Addiction Medicine
Inpatient And Other Higher Levels Of Care The following mental health, alcohol and drug treatments are covered in addition to outpatient visits: Inpatient hospital care Partial hospitalization Residential treatment at several levels 32
Detoxification Various treatments that are community-based Emergency respite (relief) care Care in a structured or intensive outpatient program (minimum nine hours per week, multiple staff, various treatment approaches) Psychological testing (other than in the first 26 outpatient visits) You must follow the steps below before getting the covered services listed above: 1. Ask your child’s doctor or counselor to call the Mental Health Case Manager before getting treatment. If your child’s doctor or counselor does not obtain preauthorization when it is required, you may be responsible for the entire cost. 2. If your child is already getting treatment when he or she enrolls, have your child’s doctor or counselor call the Mental Health Case Manager immediately. 3. In an emergency, take your child to the nearest doctor or hospital. Have the doctor or hospital call the Mental Health Case Manager immediately prior to admission and before starting treatment. Hospital employees are responsible for contacting the Mental Health Case Manager when your child is admitted and when a stay is expected to go beyond the first approval time. The hospital employees give more information to see if a longer stay can be approved. The Mental Health Case Manager will give a decision about whether or not care can be approved within three (3) business days after getting all needed information. The Mental Health Case Manager may be reached at 1-800-753-3224. The following is a list of non-covered mental health, alcohol or drug services: (This is only a partial list.) •
Testing done only to determine educational or learning problems.
•
Court ordered treatment except when pre-certified by the Mental Health Case Manager as medically necessary.
•
Two or more psychotherapy visits in the same day.
•
Any type of service provided over the telephone.
•
Any non-covered medical service delivered in a mental health, alcohol or drug treatment setting.
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How To File a Claim In the state of North Carolina most hospitals will file claims for your child. Generally, most doctors, many drug stores and mail order drug companies will also file claims. You should show your child’s ID card when you take your child to the doctor, hospital or buy a prescription drug and ask that the claim be filed with NC Health Choice. Providers, who accept your child as a patient, must accept the NC Health Choice reimbursement as payment in full and cannot bill you for the remaining cost. They can charge you for copays and non-covered services. Providers submit claims to Blue Cross and Blue Shield of North Carolina* (BCBSNC) for processing using the State Health Plan claim form. Any licensed provider in North Carolina can provide services for NC Health Choice recipients. It is not necessary for providers to enroll with BCBSNC to provide services and submit claims, but claims submitted by BCBSNC participating providers generally process for payment quicker than claims submitted by providers who are not enrolled with BCBSNC. When a doctor or other medical provider will not file a claim, you will have to file the claim yourself. Claim forms are available from Customer Service. You are responsible for making sure that all claims for covered services are filed within 18 months from the date of service. NC Health Choice will not pay claims that are not received within the 18-month time limit.
Claims for medical, mental health, alcohol and drug treatment: For questions related to claims filing, contact Customer Service at 1-800-422-4658. Complete the form and attach a copy of the doctor’s charges. The doctor’s charges must have: • Doctor’s name • Date of service • Itemized charges • Complaint or symptom (diagnosis) • Doctor’s signature Mail these types of claims to: NC Health Choice P O Box 30025 Durham NC 27702-3025 * an independent licensee of the Blue Cross and Blue Shield Association
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What Happens After Your Claim Is Processed? Each week, NC Health Choice sends a report called an Explanation of Benefits (EOB) to enrollees if claims were processed for them during the preceding seven (7) day period. If the processing of a claim resulted in payment, a check will be sent to the health care professional.
YOUR EOB IS NOT A BILL. The EOB contains information about the nature of
each claim submitted on behalf of your child. If the EOB shows your copay, it was what you paid to the health care professional at the time of your visit. You should not pay NC Health Choice. Also, do not pay your child’s health care professional unless you receive a bill directly. You can use the EOB to keep up with your copays. The back of the EOB shows your child’s name and address. It also shows information about your right to appeal claim decisions. You can also find the address for Customer Service on the back of the EOB. If You Have Questions About Your Child’s Benefits or Claims If you have questions about claims or covered medical care for your child, please call Customer Service at 1-800-422-4658. You may also write to the following address: NC Health Choice P O Box 30111 Durham NC 27702-3111 If you have questions about prescription drugs, please call the Pharmacy Benefit Manager at 1-800-336-5933. If you have questions about mental health, alcohol or drug treatment for your child, please call the Mental Health Case Manager at 1-800-753-3224. You may also write to the following address: NC Health Choice Mental Health Case Manager P O Box 12438 Research Triangle Park NC 27709-2438
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Fraud It is a crime to knowingly and willfully apply for, obtain coverage or to request and receive medical treatment by: •
making a false statement, not giving full and correct information or misrepresenting information;
•
helping another person either directly or indirectly to attempt or to actually get money, services or anything of value through NC Health Choice; or
•
misusing the NC Health Choice card by selling, changing information or letting another person use the card.
If a person commits fraud, he or she will face criminal charges and the child may be dropped from coverage.
Help Stop Fraud
Always review your Explanation of Benefits for correct information about the items or services your child received. If you suspect a fraudulent act has been committed against NC Health Choice, please report this incident to the Special Investigations Unit by calling the Fraud Hotline toll free at 1-800-324-4963.
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Medical Appeals If you have contacted Customer Service for help and you do not agree with the decision, you may file a formal appeal. Most problems can be solved without filing an appeal. Please call Customer Service first at 1-800-422-4658. All appeals must be sent in writing and received within 60 days of the date of the first denial or benefits decision. Medical and pharmacy appeals should be sent to: NC Health Choice Appeals Coordinator P O Box 3869 Durham NC 27702-3869 If you need help filing an appeal for your child, you may ask one of the following people to file an appeal for him or her: • •
person with power-of-attorney for or legal guardianship over the covered child; another person whom you have asked to submit an appeal for you, such as your child’s doctor or counselor, an immediate family member, a friend, an employee of the facility where your child received services or an employee of the department of social services or county health department, or a lawyer you may have hired. (Note: If you choose to have someone else file the appeal, you must fill out and sign a Member / Dependent Authorization Request form and submit it with the appeal. You may call Customer Service at 1-800-422-4658 to get an Authorization Request form.)
Appeals must include the following information: child’s name child’s ID number your telephone number date the service was provided name(s) of the provider(s) of service reason for appeal copy of the Explanation of Benefits or written notification of a benefits decision documentation, if needed (such as medical records, letters from a doctor, etc.) name of the representative in Customer Service who handled the inquiry your signature and date, or Member / Dependent Authorization Request form for someone who you have decided to act on your behalf, including your signature and date Benefits and services that are clearly stated as non-covered in this benefit handbook cannot be appealed, and are considered Benefit Exclusions. NC Health Choice will do a review to make sure that benefits have been correctly applied. 37
NC Health Choice offers three (3) levels of appeal.
Level One: Your request for appeal must be received within 60 days from the date of the first denial or benefits decision. You may request an appeal form from Customer Service at 1-800-422-4658. You can also write a letter providing all of the information about why you disagree with the decision. You will get a letter from NC Health Choice within three (3) business days, to let you know who will be handling your case and how to give more information, if needed. You will get a decision letter within 30 days. If you do not agree with the decision from your first level appeal, you may file a second level appeal.
Level Two: Your request for appeal must be received within 60 days from the date of the Level One appeal decision letter. You may request an appeal form from Customer Service at 1-800-422-4658. You can also write a letter providing all of the information about why you disagree with the decision. You will get a letter from NC Health Choice within ten (10) business days to let you know who will be handling your case and how to give more information, if needed. NC Health Choice will have a special meeting by telephone to review you or child’s case. You and / or someone you ask can participate in the call. An outside panel of experts will review the case and make a decision. NC Health Choice will let you know the decision within seven (7) business days of the meeting. The Level Two review can take up to 45 days to complete. If you do not agree with the decision from your second level appeal, you may file a Level Three appeal.
Level Three: Your request for appeal must be received within 60 days from the date of the Level Two appeal letter. Please follow the instructions given in your Level Two letter to request the Level Three appeal. Depending on the type of case, your Level Three appeal will either be with the NC Department of Insurance to be looked at by an independent medical expert; or by the Executive Administrator and Board of Trustees. Follow the instructions in your Level Two decision letter.
Expedited Review: You can request a faster or expedited review at any point in the
appeals process, if a delay would risk your child’s life, health, or ability to regain function. Calling Customer Service at 1-800-422-4658 can start the expedited review. The appeal process will continue as usual, but NC Health Choice will let you know whether you may continue services within four (4) days of accepting an expedited review request. All appeal decisions are based on coverage noted in the North Carolina General Statutes and in NC Health Choice’s approved medical policies.
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Mental Health, Alcohol and Drug Treatment Appeals All appeals for mental health, alcohol and drug treatment must be submitted within 60 days from the date of the letter indicating services are not covered. NC Health Choice offers three (3) levels of appeal. The Mental Health Case Manager does the first two levels. The third level is done by the NC Department of Insurance. If you need help filing an appeal for your child for mental health, alcohol and drug treatment, you may ask one of the following to file an appeal for him or her: •
person with power-of-attorney for or legal guardianship over the covered child;
•
another person whom you have asked to submit an appeal for you, such as your child’s doctor or counselor, an immediate family member, a friend, an employee of the facility where your child received services, an employee of the department of social services or county health department, or a lawyer you may have hired. Note: If you choose to have someone else file the appeal, you must fill out and sign a Member / Dependent Authorization to Release Information for Mental Health form and submit it with the appeal. (See Privacy section on page 4.)
Appeals for mental health, alcohol and drug treatment should be sent to: NC Health Choice Appeals Coordinator P O Box 12438 Research Triangle Park NC 27709-2438 All appeal decisions are based on coverage noted in the North Carolina General Statutes and in NC Health Choice’s approved medical policies.
Additional Assistance:
Managed Care Patient Assistance (MCPA) Program is available to explain your child’s rights; answer questions about managed care; provide advice about the coverage; and help you understand the review process and appeal procedures. Assistance through MCPA is not available for dental related services. Managed Care Patient Assistance Program North Carolina Department of Justice 9001 Mail Service Center Raleigh NC 27699-9001 1-866-867-MCPA (6272) toll free 1-919-733-MCPA (6272) E-mail:
[email protected]
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Commonly Used Terms
Brand Name Prescription Drug
A “brand name” prescription drug is the “brand” or “trade” name for a drug produced by one company. To reduce the amount of your copay, ask your physician if a “generic” drug substitute would be a good choice. (See definition of “Generic Prescription Drug” below.)
Child
A person age six (6) through 18 who lives in the state of North Carolina and qualifies for NC Health Choice as determined by county departments of social services.
Child With Special Health Care Needs
A child with special health care needs enrolled in NC Health Choice who has a medical or mental health condition or a problem with alcohol or drug abuse that has lasted or is expected to last for twelve (12) or more months, interferes with the child’s daily routine, and requires more medical care and family management than most children need.
Coverage
Benefits that are paid by NC Health Choice for covered medical care, mental health, and alcohol and drug treatment and prescription drugs.
Copay
Part of the charge that a covered child’s family or guardian may have to pay for covered treatment. This payment is made to the health care professional at the time your child receives the service.
Covered Service
Medical, dental, mental health, alcohol and drug treatment that can be covered under NC Health Choice.
Customer Service
Office that answers questions about NC Health Choice and gives help with processing claims.
Durable Medical Equipment (DME)
Standard equipment which normally is used in an institutional setting, can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.
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Generic Prescription Drug
A “generic” prescription drug is a drug that is made by more than one company. If your physician allows the pharmacist to choose a “generic” drug, he is free to choose a less expensive drug. This will save both you and the Health Choice Program money. “Generic” drugs are often an effective substitute for brand name drugs. The copay for a “generic” drug is less.
Letter of Medical Necessity
A statement or medical records submitted and signed by a physician to support the need for the requested service, equipment or supply.
Limits
When a service may be covered but only a certain number of visits or amount of money may be paid, or only a certain kind of doctor or medical professional can give the care.
Medical Necessity
Necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, injury, disease or its symptoms. This is defined by medical policies, the Executive Administrator and Board of Trustees of the North Carolina State Health Plan for Teachers and State Employees.
Member Health Partnerships Operations (MHPO)
Member Health Partnerships Operations administers the medical necessity process, which includes the preadmission certification of inpatient hospital admissions and certain procedures and surgeries that require prior approval.
Mental Health Case Manager
The Mental Health Case Manager is responsible for determining medical necessity for mental health services. (For specifics about when to call the Mental Health Case Manager refer to the section, “Going to the Doctor or Counselor for Mental Health, Alcohol or Drug Treatment.” See pages 31 through 33.)
NC Department of Health and Human Services (NC DHHS)
State agency that runs NC Health Choice and handles prior approval of some services for children with special health care needs.
Non-covered Services
Any care, treatment, service or supply that cannot be paid by NC Health Choice.
Pharmacy Benefit Manager (PBM)
The company with which the State of North Carolina contracts to manage the prescription drug benefits. The PBM is currently Medco.
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Plan Year
Same as the State of North Carolina’s fiscal year (July 1 through June 30).
Preadmission Certification and Length-of-Stay Approval
This process makes sure that hospital admissions and the number of days spent in the hospital are right for a child’s condition. This includes facilities and programs for medical, mental health, alcohol and drug treatment. This is different from prior approval or calling Customer Service for information.
Prescription Drug
A drug approved by the Food and Drug Administration (FDA) that can be bought only with a doctor’s written prescription. A drug that can be bought without a doctor’s written prescription is not covered.
Prior Approval
Process that makes sure that certain covered medical care and services are medically necessary to treat a child’s condition. This is different from calling Customer Service for information or getting preadmission certification and length-of-stay approval for a hospital stay.
Provider
A licensed professional, hospital, clinic or pharmacy that is eligible to provide services under the terms of the Plan. Must be certified / licensed in the state in which covered services are provided. The term “Provider” may also be used for a supplier of durable medical equipment.
Retrospective Review
When NC Health Choice is being asked to approve services for your child that have already been provided, the review is considered “retrospective.”
Wellness
Doctor visit when your child is not sick or hurt.
Year
The time period that a county department of social services says a child can be covered under NC Health Choice (not to go beyond 12 months).
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Important Telephone Numbers and Addresses
North Carolina Family Health Resource Line
(To find out general information or to apply for NC Health Choice coverage) 1-800-367-2229
Customer Service
(For general information and questions about claims) 1-800-422-4658 1-800-442-7028 (TTY line) 1-919-765-7080 (Fax #) NC Health Choice Customer Service P O Box 30111 Durham NC 27702-3111
Prior Approval
(For general information and questions about prior approval) 1-800-672-7897 1-919-765-4890 (Fax #) NC Health Choice Member Health Partnerships Operations (MHPO) P O Box 30111 Durham NC 27702-3111
Inpatient Hospital Admission for Medical / Surgical Treatment
(To get a hospital stay approved) 1-800-672-7897 1-919-765-4890 (Fax #)
Mental Health, Alcohol, and Drug Treatment
(For general information and questions) 1-800-753-3224 1-919-379-9035 (Fax #)
Mental Health Case Manager P O Box 12438 Research Triangle Park NC 27709-0438
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Children With Special Health Care Needs Help Line
(For general information and questions about services for children with special health care needs) 1-800-737-3028
Pharmacy Benefit Manager (Medco)
(For questions about prescription drug benefits and claims) 1-800-336-5933 NC Health Choice Pharmacy Benefit Manager P O Box 30493 Tampa FL 22520-3493
Dental Prior Approval
(For general information and questions about prior approvals) 1-800-672-7897 1-919-765-4890 (Fax #) NC Health Choice Dental Analyst P O Box 610 Durham NC 27702-0610
Filing All Claims (Except Prescription Drugs)
(To have your child’s doctor file claims) NC Health Choice P O Box 30025 Durham NC 27702-3025
Appeals
Mental Health, Alcohol and Drug Treatment Appeals should be sent to: NC Health Choice Appeals Coordinator P O Box 12438 Research Triangle Park NC 27709-2438 For special delivery or overnight mail service: NC Health Choice Appeals Coordinator 3800 Paramount Pkwy Suite 300 Morrisville NC 27560 1-919-379-9035 (Fax #) 44
Medical and Pharmacy Appeals should be sent to: NC Health Choice Appeals and Grievance P O Box 3869 Durham NC 27702-3869 1-919-765-2923 (Fax #) For Assistance with Appeals: Managed Care Patient Assistance Program North Carolina Department of Justice 9001 Mail Service Center Raleigh NC 27699-9001 1-866-867-6272 E-mail:
[email protected]
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NC Health Choice Handbook
NC Health Choice Handbook 2006 2008 - 2007
2006 - 2007 2008
1. Choose a doctor. Be sure he or she accepts NC Health Choice.
2. Make an appointment for a check-up. Get to know your child’s doctor and staff. When your child gets sick, you’ll have a trusted Medical Home you can turn to!
Make the MOST of your NC Health Choice benefits in 5 easy steps... Medicaid Eligibility Unit Division of Medical Assistance 2501 Mail Service Center Raleigh, NC 27669-2501
3. Call the doctor anytime you have questions about your child’s health. But especially before going to the emergency room!
4. Read this handbook. You’ll find loads of information on benefits and resources.
ADDRESS SERVICE REQUESTED
5. Re-enroll next year!
Re-enrollment packages packages come come in in the the mail, mail, so Re-enrollment so let let the the DSS DSS know know ifif you move! move! Remember, Remember, you a year keep you you must must re-enroll re-enroll once to keep yourto child’s yourHealth child’s NC Health Choice coverage! NC Choice coverage!
L1280 11/08– PLEASE – PLEASE NOT DESTROY. REMAINS EFFECTIVE UNTIL HANDBOOK IS PRINTED. L1280 3/06 DODO NOT DESTROY. REMAINS EFFECTIVE UNTIL NEWNEW HANDBOOK IS PRINTED
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