Medicare is a federal health
insurance program for persons 65
or older and their spouses at
65, or persons of any age with
end-stage renal disease (kidney
failure), and certain disabled
social security and Railroad
Retirement beneficiaries who
have received disability
benefits for at least 24
months. The original Medicare
as "fee-for-service" Plan
consists of two parts:
- Hospital Insurance (PART
A) provides institutional
care, including inpatient
hospital care, skilled
nursing home care, past
hospital home health care,
and hospice care. The Part
A program is compulsory and
is financed by social
security payroll tax
deduction (1.45% of the 7.6%
FICA Tax) withheld from
wages in 2004.
- Medical Insurance (PART
B) is a voluntary program of
health insurance, which
covers doctor services,
outpatient hospital care,
physical therapy, ambulance,
medical equipment and a
number of other services not
covered by Part A. It's
financed through monthly
premium ($66.60 a month in
2004) paid by those who
enrolled and contributions
by the federal government.
The government's share is
approximately 75% of the
cost.
Medicare does not cover
custodial care or long term
nursing home care. Much of the
care provided in a nursing home,
is to people with chronic,
long-term illnesses, or
disabilities, that care is
considered custodial and
therefore not covered by
Medicare.
ORIGINAL MEDICARE PLAN
AT A GLANCE - 2004
|
Medicare has two parts:
Part A ( Hospital
Insurance) and
Part B (Medical
Insurance). |
|
|
| PART A
SERVICE |
TIME LIMIT |
YOU PAY |
MEDICARE PAYS |
Hospital Stay:
Semiprivate room, meals,
general nursing, and
other hospital services
and supplies. This
includes care in
critical access
hospitals and inpatient
mental health care.
Inpatient mental health
coverage in an
independent psychiatric
facility is limited to
190 days in a lifetime.
|
First 60 days
per Benefit
Period |
|
--------------------
|
|
Next 30 days of
confinement
|
|
--------------------
|
|
Additional 60
lifetime reserve
days (once used
not replaced)
|
|
--------------------
|
|
Beyond 150 days
|
|
$952.00
Maximum |
|
--------------------
|
$238.00
a day |
|
--------------------
|
$476.00
a day
|
|
--------------------
|
|
All Cost |
|
Balance
Does not
include: First 3
pints of blood,
private duty
nursing, TV,
telephone, or
private hospital
room, (unless
medically
necessary).
|
|
----------------
|
|
Nothing |
|
Skilled Nursing Facility
(SNF) Care:
Semiprivate room, meals,
skilled nursing and
rehabilitative service,
and other service and
supplies (must occur
within 30 days of
hospital confinement
which lasted 3 or more
days).
|
First 20 days
per
Benefit Period
|
|
----------------
|
Next 80 days of
continuous
confinement
|
|
----------------
|
|
Beyond 100 days
|
|
Nothing
|
|
----------------
|
$119.00
a day
|
|
----------------
|
|
All Cost |
|
|
100% of approved
charges |
|
----------------
|
Balance
|
|
----------------
|
|
Nothing |
|
Hospice Care:
Medical and support
services from a
Medicare-approved
hospice, drugs for
symptom control and pain
relief, short-term
respite care, care is a
hospice facility,
hospital, or nursing
home when necessary, and
other services not
otherwise covered by
Medicare. Home care is
also covered.
|
Two 90 day periods
followed by an unlimited
60 day periods |
Up to $5 for outpatient
prescription drugs and
5% of approved amount
for inpatient respite
care. |
Balance
Doctor must certify that
you are terminally ill
and you elect to reserve
these services. |
|
|
| PART B SERVICE |
TIME LIMIT |
YOU PAY |
MEDICARE PAYS |
Medical And
Other Services:
Doctors'
services,
outpatient
medical and
surgical
services and
supplies,
diagnostic
tests,
ambulatory
surgery center,
facility fees
for approved
procedures, and
durable medical
equipment. Also
covers second
surgical
opinions and
outpatient
physical and
occupational
therapy
including
speech-language
therapy.
|
|
--------------------
|
|
Outpatient
mental health
care: |
|
--------------------
|
|
Outpatient
Hospital
Services:
For the
diagnosis or
treatment of an
illness or
injury. |
|
--------------------
|
|
Clinical
Laboratory
Services:
Blood tests,
urinalysis, and
more. |
|
No Limit
(except one
deductible per
calendar year)
Exclusions: Most
prescription
drugs and
medicines taken
at home;
long-term
nursing home
care and
custodial care;
services not
reasonable or
medically
necessary;
routine physical
exams, eye
exams, glasses,
hearing aids,
and dental care;
routine foot
care and
orthopedic
shoes, except
for diabetics;
nearly all
services outside
the U.S.; and
most
immunizations (pneumococcal
vaccine and flu
shots are
covered). |
|
First $124.00
each calendar
year then 20% of
approved amount
plus any charges
above approved
amount and costs
for the first 3
pints of blood
in a calendar
year.
|
|
--------------------
|
|
50% of approved
amount |
|
--------------------
|
|
20% of approved
amount |
|
--------------------
|
|
Nothing |
|
80% of approved
amount with some
exceptions (when
services are
covered with no
cost-sharing)
|
|
--------------------
|
|
50% of approved
amount |
|
--------------------
|
|
80% of approved
amount |
|
--------------------
|
|
100% of approved
amount |
|
|
|
Home Health Care
(Part A and B): |
TIME LIMIT |
YOU PAY |
MEDICARE PAYS |
|
Part-time
skilled nursing
care, physical,
occupational,
speech-language
therapy, home
health aid and
medical social
services. |
|
--------------------
|
Durable
Medical
Equipment:
and medical
supplies, and
other services.
|
|
First 100 visits
per spell of
illness (must be
home confined)
|
|
--------------------
|
|
No Limit |
|
Nothing
|
|
--------------------
|
|
20% of approved
amount |
|
100% of approved
amount (Doctor
must set-up a
plan of
treatment)
|
|
--------------------
|
|
80% of approved
amount
|
|
Sources: "Medicare & You 2005,"
Centers for Medicare & Medicaid
Services, U.S. Department of
Health and Human Services, 2002;
"Mutual Care®," Mutual of Omaha
Insurance Company, 2004.
|
