When Is Medicare Secondary?

When Is Medicare Secondary?

The Part B deductible of $183.00 must be met before Medicare starts to pay. Many private health insurance plans have a similar deductible. Once the deductible is met, you may be on the hook for 20% of the Medicare-approved amount for the first “gap” of $2,010.00 (the difference between the $4,950.00 ER benefit and the $3,940.00 allowance for the first 60 days in the hospital) and 100% of any amount in excess of the $2,010.00.

Medicare normally pays 80% of a physician's charge for a medical procedure, but it will pay 100% for claims that involve critical access hospitals or community health centers, or if the services are covered by Medicare through an outpatient department of a hospital.

Medicare will pay only for professional services and supplies that are medically necessary and are documented in your medical records. Medicare may not pay for services used for legal or psychotherapeutic purposes.

For additional information regarding Medicare and your medical condition, contact Medicare at 1-800-MEDICARE (1-877-690-1012) and request a free copy of their booklet The Official Medicare Handbook.

What are the differences between Medicare and Medicaid?

Medicaid is a joint state and federal program to provide medical assistance to certain persons who are in need of financial assistance. Eligibility is based upon income, assets and disabled status. If you are eligible for Medicaid, you will need to apply for the program. The application process is handled by the Local Social Services Agency; there is no charge to apply.

Medicare is a federal program providing hospital insurance for people age 65 and over, and a health insurance program for those age 65 and over who are disabled.

What is Medicare Supplement Insurance?

Medicare Supplement Insurance helps fill the gaps in Medicare coverage. Medicare only pays 80% of approved charges. In addition, Medicare does not pay for certain services. Non-covered services may include:

- Routine eye exams

- Routine dental exams

- Prescriptions drugs

- Dental and eye exams

- Hearing exams

- Home Health Care

- Long-term care

- Skilled Nursing Facility Care

- Outpatient Therapy

- Oxygen

- Durable medical equipment

Medicare Supplement Insurance helps pay these non-covered services.

What kind of things does Medicare not pay for?

Medicare does not pay for a number of items and services, including:

- Care in a foreign country or care by an overseas doctor

- Health insurance offered through an employer that duplicates Medicare coverage

- Cosmetic surgery, such as face lifts

- Physical checkups, other than those approved by Medicare

- Routine dental care, routine eye exams and routine hearing exams

- Prescription drugs not approved by Medicare

- Over-the-counter medicines

- Health club dues, swimming or exercise classes

- Transportation to medical appointments

- Skilled nursing home care

- Outpatient physical therapy

- Medical tests you had before you enrolled in Medicare

- Smoking cessation programs

- Weight-loss programs

- Extended care (skilled nursing facility care) - you must have a chronic health condition

What is Medicare's prescription drug program?

Part D of Medicare, began in 2006, was passed under the Medicare Modernization Act. This program makes it possible for Medicare beneficiaries to receive prescription drug coverage. For more information, call 1-800-MEDICARE (1-877-690-1012).

If I am age 65 or over, am I eligible for Medicare?

Yes, if you have paid enough Social Security taxes through your Social Security W-2 and 1099 income tax forms. If your spouse is 65 or older, or is disabled, you can get Medicare coverage for him or her. You must apply for Medicare within 3 months of your 65th birthday.

How does my spouse get Medicare?

If your spouse is age 65 or over, or is disabled, he or she may be eligible for Medicare. You must apply for Medicare within 3 months of the month your spouse becomes 65 or if your spouse becomes disabled. If your spouse is under 65 and is disabled, he or she is eligible for Medicare and you can apply for Medicare on his or her behalf.

How does my spouse get Medicare if he or she works?

If your spouse is under age 65 and works, he or she may be eligible for Medicare. He or she must work at least 10 hours per week and earn at least $1,200 per month from employment or self-employment. If she or he is a farmer, he or she can be self-employed and receive Social Security payments at age 65.

How much will it cost me to get Medicare?

There is a one-time, up-front premium for Part A and Part B. There is a one-time, up-front premium for Part A and Part B of Medicare. The premium for Part A is $437 per month if you are eligible for premium-free Part A based on your work record. The Part B premium for the first year is $96.40 per month, and it is subject to change annually. Part D premiums are not subject to change.

What is Medicare's premium?

Part A is a premium-free hospital insurance program for people who have worked in jobs covered by Social Security for at least 10 years. The premium for Part B is $96.40 per month for the combined Part A/Part B, or $104.90 per month if a single Part B is purchased.

What is the Medicare enrollment period?

You must enroll in Medicare three months

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