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Medicare made simple

For the year 2003

Medicare: an introduction

Medicare becomes available at the beginning of the month in which you turn 65, whether you are retired or still working. Medicare may also be available if you are disabled or if you have chronic kidney disease. Such eligibility can be for benefits as a spouse of a retired or disabled worker or as a surviving spouse of a deceased worker. Also, a disabled child of a retired, disabled or deceased worker is eligible.

The Medicare program has two parts. Part A covers hospital stays. Part B is supplementary and covers physician bills.

If you are disabled, you may be eligible for Medicare Part A before age 65. You must have been entitled to disability benefits from Social Security for at least two years as a disabled worker, surviving spouse, or child.

You automatically apply for Medicare when you apply for Social Security benefits. If you plan to work past age 65, you should apply for Medicare separately when you turn 65.

Remember to contact the local Social Security Administration office to apply for your Medicare card about three months before you turn 65.

What benefits are covered at our hospital?

Our hospital provides the basic Medicare benefits, including Medicare Part A inpatient hospital care. We provide additional Medicare Part A benefits through our Transitional Care Unit, the Pathways mental health program for older adults, home health services and a hospice care program.

Medicare usually only covers medically necessary services. Medicare specifies beforehand the limits and allowable amounts that apply to certain charges. You are responsible, in most cases, to pay part of the costs of covered services. Those coinsurance amounts usually change every year.

The following descriptions are based on amounts announced for 2003.

Hospital benefits
Each time you are admitted to a hospital, you are responsible for the initial Part A deductible of $840. If your hospital stay extends from 61 through 90 days, you will be responsible to pay a coinsurance of $210 per day. If your hospital stay extends from 91 through 150 days, you can designate to use your "lifetime reserve" days, for which you will be responsible to pay $420 per day. You are given a total of 60 "lifetime reserve" days, which are nonrenewable and cannot be recovered once used. (We can provide you with a pamphlet on supplemental Medicare insurance policies that explains how a supplemental policy can help cover some costs Medicare doesn't.)

Your benefit period ends 60 days after you have been discharged from the hospital or from a skilled nursing facility. A "benefit period" is a common way of measuring your use of services under Medicare Part A. Your first benefit period begins when you are admitted to a hospital for the first time after your Medicare coverage begins. Again, your benefit period ends after 60 consecutive days after discharge from the hospital or skilled nursing facility.

If you have another hospital admission 60 or more days after your last discharge, you begin a new benefit period with the same benefits described above under "Hospital benefits," including being responsible for another Part A deductible of $840.

Skilled nursing facility benefits
Skilled nursing facility benefits are available to you only following a hospital stay of at least three days and only if the benefits begin within 30 days after being discharged from the hospital. If you qualify for these benefits, you are not responsible for any charges within the first 20 days, except for any charges Medicare does not allow. For the next 80 days, you will be responsible for charges up to $105 per day, and Medicare will be responsible for the rest of the charges. No benefits are available after 100 days of care within a given benefit period.

Home health services benefits
Home health services, such as part-time or intermittent skilled nursing care, physical therapy, medical social services, medical supplies and some rehabilitation equipment, may be paid in full by Medicare when you are confined at home, as long as the services are prescribed by a doctor.

Hospice benefits
Hospice furnishes a coordinated program of inpatient, outpatient and home care for terminally ill patients. All other Medicare benefits stop when you choose hospice benefits, except for conditions not related to the terminal illness. You are responsible for 5 percent of the cost for respite care (inpatient care), not to exceed five consecutive days. However, you will only be responsible for a maximum of $840 within a hospice care period. Hospice benefits are limited to 210 days unless you are recertified as being terminally ill.

Medicare pays the hospital a fixed amount for your hospital stay, according to your diagnosis, to avoid excessive hospital stays. However, you and your doctor still decide when you are ready to be discharged.

Outpatient benefits (Medicare Part B)

Almost everyone is eligible to enroll in Medicare Part B upon reaching age 65. However, you will be responsible for a monthly premium, which is automatically deducted from your Social Security benefits.

Enrollment in Medicare Part B is automatic when you enroll in Medicare Part A. You may reject enrollment by notifying your local Social Security office and indicating you do not want to receive coverage. You may decline participation in Part B at any time.

You are responsible for the first $100 of allowable Medicare charges each calendar year. Part B will then pay 80 percent of all covered outpatient services. The Part B monthly premium for calendar year 2003 is $58.70.

What Medicare does not cover

Medicare does not cover some expenses. The best way to inquire about specific cases is to call the local carrier that administers Medicare benefits to specific regions. Our local carrier is Blue Cross of Western Pennsylvania (1-800-345-7808).

Here are some items not covered by Medicare:

• Routine physical exams, including more than one pap smear or mammogram in three years.

• Dental services (unless for a jaw fracture).

• Cosmetic surgery (unless needed after an accident).

• Private rooms (over and above the average daily semi-private room charge).

• Services that should be covered by liability or automobile insurance, which takes precedence.

Coordination of Medicare with other insurance

If you are eligible for Medicare benefits and are neither working nor married to a working person with employer-based coverage, then Medicare ordinarily pays your medical bills before any other insurance coverage.

If you are eligible for Medicare benefits at age 65 and are working for an employer with 20 or more employees, and you or your spouse chooses to be covered under your employee benefit plan, then Medicare is the secondary payor, paying only the charges not covered by your employee benefit plan.

These same rules apply to any disabled Medicare enrollee or family member of a current employee who is also covered by an employer-based health care plan of 100 or more employees.

Medicare is also the secondary payor when medical care can be paid for under any liability policy, such as automobile or Worker's Compensation.

The rules for paying claims when Medicare is secondary are complex. Informing our registration personnel at the time of your visit will help avoid any unnecessary delays in processing your account.

If you have questions, please call Patient Accounts at 949-4550.

Your Medicare card has vital information

When you become eligible for Medicare benefits, you will receive a Medicare card containing your name and claim number.

This number is very important and the card should be presented to the registration clerk at the time of your visit, because no claim will be paid without the correct claim number.

The card is the only evidence that you are covered by Medicare. Please have it with you when you arrive!

We at Bon Secours-Holy Family Hospital are committed to being as helpful as possible during your visit, and that means settling your claims as quickly as possible.