Posts tagged 'General-Medicare'
No matter what Medicare Plan you are on, you have the right to appeal any decision about your Medicare coverage. If Medicare does not pay for an item or service that you feel you are entitled to, you can appeal that decision.
This is not necessarily an easy process; however, there are ways it can be done. For instance, there are various appeal forms depending upon what plan you are on. They are available by downloading from the internet or calling the Medicare program you are enrolled in. The information should be on your Medicare card and your monthly statement.
If you file an appeal, Medicare has a limited amount of time to respond to you and at least let you know that they are looking into the matter. Often, you will hear from them in 7 to 10 days.
If you are not satisfied with any decisions regarding your appeal, you will be advised as to the next level you can go to. It is similar to taking a matter to civil court, then superior court then district court then the Supreme Court. With Medicare, hopefully you won’t have to go all the way to court.
There are five levels to an appeal. First, redetermination by a Medicare carrier, intermediary, or Medicare Administrative Contractor. Second is review by a Qualified Independent Contractor. Third is hearing by an Administrative Law Judge in the Office of Medicare Hearings and Appeals. Fourth is review by Medicare Appeals Council, and Fifth is Judicial Review by Federal District Court. Most cases are settled long before they get to step number five.
No matter what your question, grievance or appeal is, try to start by getting information directly from your Medicare provider. This may take some work, research and time, but it can save a lot of time and effort in the long run if you do not have to go through the entire appeals process.
For questions or information, call Medicare at 1-800-MEDICARE.
Medigap plans are designed to cover the “gaps” or expenses that Medicare does not cover. They help pay for these services and are sold by private companies. It is important to research companies and plans if you are thinking of purchasing this type of coverage.
Another important thing to be aware of regarding Medigap coverage is that if you decide to purchase this type of coverage, you should do so within six months of getting Medicare Part B. The reason this is so important is that because during this six month period insurers cannot deny you Medigap coverage. In addition, they can not postpone the time when your coverage starts and they cannot charge you additional rates based on pre-existing health conditions – health problems that you already have. This is critical if you are dealing with serious or ongoing health issues, such as diabetes, high blood pressure, heart problems and more.
If you wait until after the six month period, you could be denied coverage; there is no guarantee that you will be able to be approved.
There is information available regarding Medigap insurance and it is a very good idea for you to research this information. There are a number of places to find this information by going on the internet. The easiest way is to go to Google and type in Medigap Insurance. In addition, go to www.ssa.gov and look under Medicare coverage and there will be links to Medigap information as well.
Medicare is designed for individuals 65 years old or older, and individuals with disabilities or on renal dialysis. Medicare Part A covers hospital and inpatient services, while Part B covers doctor visits and other services received as an outpatient (outside of the hospital).
Many people worry about how to enroll in Medicare. They worry that it will be difficult or confusing, but it doesn’t have to be, and it usually isn’t.
If you are receiving Social Security benefits, you will automatically be enrolled in Medicare Part A & B on the first day of the month that you have your 65th birthday. In other words, if you turn 65 on February 10th you will be enrolled at the beginning of February.
Your Medicare card will come in the mail up to three months before your 65th birthday. If you do not receive it in a timely manner, you should call the Social Security Administration at 1-800-772-1213 or visit them on the internet at www.ssa.gov. Either way, you will get assistance and can have the Medicare card sent to you.
If you are not receiving Social Security, you will need to sign up for Medicare. This is an easy process and you can do this a couple of ways. You can call Social Security Administration at 1-800-772-1213. They will take the information over the phone to get the process underway and then they will send you some paperwork in the mail.
If you prefer, you can go to your local Social Security office and apply in person. The advantage to this is that there is an individual there who will walk you through the entire process. Either way, it is your choice. You cannot, however sign up on line for Medicare only.
To sign up for both Medicare and Social Security Retirement Benefits together you can apply online at www.ssa.gov, or by phone at 1-800-772-1213, or go in person to your local Social Security office. Either way, you should be able to easily get enrolled for Medicare benefits without extra effort or worry.
One of the biggest worries that individuals with disabilities have when they attempt to work is the loss of benefits – especially health care coverage. They are worried that they will have no coverage at all or be forced into an employer’s plan that they cannot afford or that won’t cover their disability.
There are solutions to this dilemma, however. The solutions are found as part of the Social Security Act- especially part 1619b and Medicare. One of the most important provisions is the Medicaid Buy-in program. This program was designed to provide access to comprehensive health care for working people with disabilities. This is essential for many people with disabilities who find it difficult to find affordable and comprehensive coverage privately.
The Medicaid Buy-in program allows people with disability to pay a premium for coverage through their state’s Medicaid program, just as they would if they were buying private health coverage. The concept behind the buy-in was originally put forth in the Balanced Budget Act of 1997 to allow for individuals who lost SSI or SSDI benefits because they were making more money working. These individuals were able to support themselves without receiving SSI or SSDI checks because they were making enough money through their paychecks from work. However, they still needed health coverage, and Medicaid was the best choice for many situations. As long as the individuals continued to meet the Social Security definition of disability, they would be eligible for the buy-in program.
If you find yourself in this type of situation, there are several steps you can take. You can contact your county health department to determine what local programs are available; you can check with your state Medicaid office to see whether you qualify for the Medicaid Buy-in or other benefits; and you can check the Social Security Administration, Medicaid or Medicare websites for further information.
When you become eligible for Medicare at age 65 or because of a disability, you will automatically receive original Medicare benefits.
Something you may not realize is that depending upon the state you live in, you may be entitled to two other choices. These choices provide more coverage for issues that original, basic Medicare does not cover.
One choice is Original Medicare with supplemental insurance, such as a Medigap or retiree plan. The other choice is a Medicare Private Health Plan, also known as a Medicare Advantage Plan, such as a Health maintenance Organization (HMO), a Preferred Provider Organization (PPO), a Point of Service Plan (POS), a Provider Sponsored Organization (PSO), a Private Fee For Service Plan (PFFS), a Special Needs Plan (SNP) or a Medicare Medical Savings Account (MSA).
All of these plans provide various forms of coverage that is different than original Medicare. In addition to these plans, Medicare Part D is available to cover prescription drugs. If you are covered by original Medicare, it is important that you find additional coverage that will work well with your coverage. Often, a stand-alone prescription plan that only covers drugs (PDP) is the best choice.
A Medicare private health plan can be obtained to fulfill the health plan’s benefit package that covers drugs. If you join a PFFS without drug coverage or an MSA, you can get stand-alone drug coverage.
Regardless of which type of plan you decide on and depending upon what is available to you where you live, it is essential that you research available plans and coverage and decide what will be the best for your situation.
This is an important question, because there are a lot of recipients that want to work. There are provisions called “work incentives” for those individuals.
One provision is the Ticket to Work- Work Incentives. These include being able to work during a “Trial Work Period” which allows you to work and see how things turn out. You will NOT lose your benefits automatically during the Trial Work Period; you will receive full benefits no matter how much you earn. You only need to report your work activity.
The Trial Work Period lasts until you accumulate 9 months of work (not necessarily consecutive months) within a 60 month period of time. Once you have accumulated 9 months of work, you can earn up to $900 per month without losing your benefits. For additional 36 months after the Trial Work Period any time your income falls below $900 per month, your benefits will be automatically reinstated.
If you are disabled and working, your Medicare benefits continue for 4.5 years after you begin work, and there is no premium charge for Medicare Part A. Because of the work incentives, the coverage for individuals with disabilities trying to work, is FREE during that period of time.
If you are trying to work and receiving Medicaid, there are provisions available for most states to be able to provide any Medicaid recipients with disabilities. It is important that you check with your state Medicaid office to determine if you can maintain your Medicaid while working.
Medicaid has taken a giant and important leap recently. Because of this move forward, it is now possible that thousands of people will be able to get home-based care rather than being institutionalized. This new provision allows people to get care in their homes or in the community instead of an institutional setting.
The Deficit Reduction Act (DRA) allows states to provide people who qualify for Medicaid benefits to receive this care without having to apply for a demonstration waver to prove their eligibility. Having the option as to how an individual will receive long-term support is an historic step in leveling the playing field.
Individuals will now be able to receive person-centered care and have a part in the development and decision making about that care. Some of the services that states will be able to provide under this new provision will be case management, homemaker, home health aide, personal care, adult day health and respite care. In addition, individuals with chronic mental illness can receive day treatment, partial hospitalization, psychosocial rehabilitation and clinic services.
This new provision is an essential step in helping individuals with disabilities have the choice to be part of and participate in the community, stay in their own comfortable surroundings, make choices regarding services and have the support of a program that will offer them these options and more.
Many people have questions about Medicare and Medicaid including the question of what the differences are between the programs. There are some major differences between the two.
Medicare is funded by the federal government as an entitlement program, which mainly focuses on the older population. It is a social insurance program for individuals age 65 and over and it covers many individuals with disabilities. Medicare also covers individuals of all ages with end stage renal disease.
There are several parts to Medicare. Part A covers hospital bills, Part B covers medical insurance and Part D covers prescriptions.
Medicaid is different from Medicare in several ways. It is also an entitlement program, however, Medicaid is not funded only by federal government, there is a state component as well, and in some states, counties pay part of the cost.
Medicaid is based on need and social welfare, with eligibility based on income. If a person has limited income and/or financial resources, Medicaid covers a broader spectrum of services than Medicare does. It usually covers children, pregnant women, parents of eligible children, seniors and individuals with disabilities. Though poverty is used to determine eligibility, a person must fall into one of the coverage groups in addition to being determined eligible due to being in poverty. Medicaid benefits are paid directly to the provider of services. In addition to covering individuals who meet financial requirements, in some states Medicaid covers individuals who cannot otherwise afford insurance.
Some individuals qualify for coverage by both programs.
Next Posts
