Senior Resource Directory Senior Resource Directory

PAYING FOR HEALTH CARE
Medicare
Medicare is the federal health
in sur ance program which began
in 1966. Local Social Security offi
ces take applications and provide
information and as sis tance. The
government contracts with private
insurers (carrier or fi scal intermediaries)
to handle claims. Medicare
covers persons age 65 and over who
are entitled to Social Security benefi
ts, some disabled persons, and
persons with permanent kidney
failure. Medicare may be purchased
by people over age 65 who are not
eligible under these guidelines.
Contact your nearest Social Security
offi ce for details.
Applying for Medicare
You may apply for Medicare en roll -
ment during the seven months beginning
three months prior to your
65th birth month and ending three
months after your birth month.
Medicare is divided into two parts.
Part A is in sur ance in tend ed to
cover hos pi tal iza tion and certain
other specifi ed types of care. Everyone
who qualifi es for Medicare
receives this por tion au to mat i cal ly.
Part B, which is outpatient medical
in sur ance, is op tion al. There is
a monthly charge for Part B, and
the amount will be deducted from
your Social Security check. Most
people choose to enroll in Part B. If
you delay there is a 10% penalty on
the monthly Part B premium for
each year you delay. This penalty
continues for the remainder of
your life.
If you continue to work past age
65 and have medical coverage
through your place of em ploy ment
or your spouse’s em ploy ment, you
may now delay your enrollment in
Medicare Part B until the time you
or your spouse do retire with no
attached pen al ty .
To Find Out About
Coverage
Social Security has free pam phlets
that describe Medicare coverage.
Medicare and You, a handbook, is
updated regularly and is an invaluable
tool in answering many questions
as they arise. Local programs
exist that can answer the many
ques tions you may have about
your Medicare benefi ts. Be aware
that there are a number of seemingly
medically related pro ce dures
that are not covered by Medi care.
It is best to ask your physician if
procedures that s/he rec om mends
are covered.
The Medicare Telephone Hotline
acts as a referral service and can
provide publications on Medi care.
Contact: Medicare Tele phone
Helpline at 800-Medi care, (800-
633-4227). One can also call the
Fraud and Abuse Hotline 800-447-
8477 to report suspected Medicare
abuse or fraud and improper sales
prac tic es of Medi-Gap policies.
Medicare Assignment
When a claim is submitted to the
Medicare carrier, there will be a
determination made regarding the
“Medicare approved amount” for
whatever procedures were done.
If the doctor agrees to accept that
amount as payment in full for
services ren dered, that is known as
accepting “Medicare Assignment.”
The Medi care Carrier will send a
check for 80% of the amount to
your physician if the annual Part
B deductible has been met. The
patient is then only re spon si ble for
the re main ing 20% (plus any part
of the annual deductible not yet
paid). Without an “as sign ment”
agree ment, the patient and/or his
sup ple men tal in sur ance carrier is
responsible for excess charges up
to 115% of the Medicare approved
amount.
78 2005-2007 SANTA BARBARA COUNTY SENIOR RESOURCE DIRECTORY
Many doctors do not accept as sign -
ment. Some doctors and suppliers
will accept it for some services and
not for others. In all cases YOU
must request as sign ment.
Filing a Claim
Part A & B
The hospital, doctor or other
provider sends claims for ben e fi ts
under Part A or B, to the Medicare
carrier. You will receive notice of
payment to the provider if the
provider accepted as sign ment or a
check payable to you if the provider
did not accept as sign ment. Be
sure to deposit the check promptly
and you should pay the provider
the amount owed. Be sure you can
furnish the hospital or doctor with
your Medicare number and information
about any other health
insurance that you might have.
You are responsible for the deductible
and co-payments. If you have
sup ple men tal insurance it may pay
part or all of the remaining balance.
Appealing a Benefi t De ci sion
You have the right to appeal a
Medi care claim denial. You may
use a copy of the Medicare Summary
Notice or the Ex pla na tion of
Medicare Benefi ts that you receive
from the Medicare carrier or fi scal
in ter me di ary to document your
reasons for appealing. Attach any
additional information from the
provider to support the claim. (See
Health Insurance Coun sel ing for
local programs that can assist you
with your Medicare ap peals.)
Where to Get Help
You may call the phone number
listed on the Medicare Summary
Notice or Explanation of Benefi ts
for clar i fi ca tion of your claim. You
may call the local Health Insurance
Counseling and Ad vo ca cy Program
at 800-434-0222 for assistance in
fi ling an appeal.