Frequently Asked Questions
Q. What is Medicare?
A. It is a federal health insurance program referred to as Original Medicare,
which includes people 65 years of age, or older, certain people with disabilities who are under age 65 and those with end-stage
renal disease (permanent kidney failure). It pays for a large portion of the health care expense but not all of it.
The portion that Medicare does not pay is what the individual must pay for out of pocket such as coinsurance, co-payments,
and deductibles. The gaps in Original Medicare coverage are commonly filled by a Medicare Supplement plan. Medicare
in Texas and Texas Medicare plans are the same as Medicare in any state because it is a federal government that defines what
the benefits are.
Q.What
are the four parts of Medicare
A.•Texas Medicare Part A: This covers area such as inpatient hospital, inpatient skilled nursing
facility, home health, and hospice services. Most people do not have to pay for Part A due their contributions over 10 years.
•Texas Medicare Part B: provides covers outpatient and physician services. It also pays
for other areas such asdurable medical equipment, prosthetic devices, supplies incident to physician's services, and ambulance
transportation. Most people pay monthly for Part B.
•Texas Medicare Part C: Are Medicare Advantage plans
are offered by private insurance companies that serve as an alternative to Medicare. These plans can cover medical only
or medical and dental. These plans are subsidized and regulated by the Federal government.
•Texas Medicare Part D: Prescription Drug Coverage plans are offered by private companies to provide coverage for prescription
drug costs. These plans are subsidized and regulated by the Federal government.
Q.Can you tell me more about Medicare Part A and Part B?
A.
Part A referred to as hospital insurance, helps pay expenses for inpatient hospital care, some skilled nursing
facility care, hospice care, and some home health care. The medical costs you incur with Medicare Part A include a large
deductible per benefit period and copays if you are in the hospital for over 61 days. The benefit period for part A
is your time in the hospital including 60 days after you are release.
Part B referred to
as medical insurance, helps pay for outpatient hospital care, doctors' services, and some other medical services and supplies
when they are medically necessary that Part A does not cover. The Part B deductible is based on a calendar year and is generally
affordable. After the deductible is met you will be responsible for 20% of your Medicare Part B expenses. This
can be quite expensive if you have any major medical treatment.
Q. What is a Medicare Supplement plan?
A.A Medicare supplement insurance plan is a health insurance
policy sold by private insurance companies (Texas Medicare carrier) to cover some or all of the gaps created my Original Medicare.
The insurance companies offering a Medicare supplement plans must follow strict federal and state laws when providing the
plans to protect you. In the end, a Medicare Supplement plan may help you save on out of pocket costs even though you have
to pay a monthly premium to the insurance company you purchase the policy from. You are eligible for this plan if you
have Medicare Part A and B and are at least 65 years of age (unless disabled). Since the Medicare supplement plans do
not have an open enrollment period you can switch another Medicare supplement plan with another insurance company at any point
throughout the year as long as you qualify medically.
Q.Which
plan is right for me a Medicare supplement or a Medicare Advantage plan?
The answer will
be based on what your individual needs, concerns and financial budget. Texas Medicare Advantage plans and Texas Medicare supplement
plans have very different benefits. It is important to evaluate the premium, out-of-pocket expenses and who the Texas
Medicare providers will be on each Texas Medicare plan. Determine what the Texas Medicare guidelines and Texas Medicare
benefits are for each product and what that means to you having Medicare in Texas.
Q.How do I find the nearest
Texas Medicare Office?
A. Contact your nearest Social Security Administration office - Monday through Friday 7 a.m. to 7 p.m., Central Time Toll-free 1-800-772-1213
or toll-free TTY 1-800-325-0778
Q.What is included in Medicare's category for Durable Medical Equipment (DME)?A.It includes, but is not limited to: Diabetic supplies,Canes, crutches, walkers, Commode chairs,Home
oxygen equipment,Hospital beds, Wheelchairs
Q. How does Medicare cover me when I receive medical services aboard a cruise
ship?
A.Medicare will only pay for medically necessary shipboard services if the services were
provided while the ship was within United States waters (i.e., in a United States port, or within 6 hours of departure or
arrival at a United States port). For more infomation read the brochure: Medicare Coverage Outside the United States.
Q. What is Part D?
A.In January 1, 2006
a federal program the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) called Medicare Part D
was created to subsidize the costs of prescription drugs for Medicare beneficiaries
Q. Can I purchase the oxygen equipment I am using instead of renting? Will
Medicare pay?
A. The Medicare law prohibits payments for purchase of oxygen
equipment. If you want to buy your own oxygen equipment, Medicare cannot pay.
Q. How do I find a Texas Medicare carrier?
A.
Whether you are looking
for Medicare in Dallas Texas, Medicare
in Houston Texas or Medicare
in San Antonio Texas the process is the same. Look for the expert resources of an independent insurance agent that can
shop for not only the best Texas Medicare Supplement rates but the best plan that meets your individual needs. The Texas Medicare
requirements are the same for each Texas Medicare program because they are standardized by the federal government. If
you shop BCBS Texas Medicare or Cross of Texas Mediare or Mutual of Omaha, Plan F offers the same benefits. The only
area that will change is the cost and perhaps the carrier may offer some additional benefits such as a disounted fitness membership.
Q. Does Medicare Part A include a Hospice benefit?
A. Yes. Medicare Part A includes Hospice as a benefit. Medicare Part
A beneficiaries are entitled to hospice benefits if they are terminally ill and have less than six months to live. Hospice
benefits include doctor services, medical equipment and supplies, and nursing services among other things.
Q. I have heard that Plan F is the most popular Medicare Supplements
in Texas, is that true?
A.Yes. Texas Medicare Supplement Plan F is probably the most popular
plan because it covers all the deductibles and all the coinsurance. So if it is a Medicare approved expense, you will pay
nothing. Another popular Texas Medicare Supplement is Plan G. The primary difference is Plan G Medicare Supplement does
not cover the Medicare Part B deductible.
Q. I have a question about my bill, what should I do first?
A. You should contact your provider to discuss your concerns.
If you have any additional questions to be answered or problem resolved, then contact 1-800 MEDICARE.
Q. Is there a list of doctors and hospitals I must use with a Texas Medicare Supplement policy?
A. With a Texas Medicare Supplements you can
go to any doctor or hospital in the United States as long as they accept Medicare. The Texas Medicare Supplements also
have Select plans, which specifies the hospitals you can go to.
Q.What services are covered by Home Health Care?
A.Medicare services include: periodic and part-time skilled nursing care; speech, physical
and occupational therapy; durable medical equipment (which includes wheelchairs, hospital beds, oxygen, and walkers); medical
social services and supplies as well as other items.
Q.What is Social Security Disability Insurance (SSDI)?
A.Started in 1954, Social Security Disability Insurance or SSDI was created to
provide individuals with an income if one was not able to work because of some sort of disability or even temporary injury
or if your condition does not improve. It is a payroll tax funded federal insurance program where a certain amount of the
FICA taxes are deducted for SSDI, Social Security Retirement and Medicare.
Q.Who qualifies for the Specified Low-income Medicare Beneficiary (SLMB) Program?
A. The SLMB program is for individuals where
a Medicare Savings Program helps pay for Medicare Part B premiums that would normally be deducted from the Social Security
checks. This is for individuals that are eligible for Medicare Part A and Part B with income at or below 120% of the Federal
Poverty Level (per month: individuals ($1,083; couples $1,457), and in addition their assets at or below the limit (individuals
$4,000; couples $6,000).
Q.What
are the qualifications to be a Qualified Medicare Beneficiary (QMB)?
A.
The QMB program is for individuals where a Medicare Savings Program that pays for their Medicare
Part A and Part B , coinsurance, deductibles and premiums. This is for individuals that are eligible for Medicare Part A and
Part B with income at or below 100% of the Federal Poverty Level (per month: individuals $903; couples $1,215), and in addition
their assets at or below the limit (individuals $4,000; couples $6,000). Keep in mind that this program will not apply benefits
retroactively.
Q.What are the requirements for a Qualified Individual-1 (QI-1)?
A. The QI-1 program is for individuals where a Medicare Savings Program that pays for
their Medicare Part B premiums. This is for individuals that are eligible for Medicare Part B with income less than 135% of
the Federal Poverty Level (per month: individuals $1,209; couples $1,640), and in addition their assets at or below the limit
(individuals $4,000; couples $6,000).
Q.What
are the qualifications to be a Qualified Disabled Working Individual (QDWI)?
A. The QDWI program is for beneficiaries on Social Security Disability Insurance
(SSDI) who due to job loss “earnings” lose their free Medicare Part A. This is a Medicare Savings Program
that will pay for Medicare Part A premiums. This is for individuals that are not 65 years old who are normally eligible
for Medicare Part A. These individuals are also at or below 200% of the Federal Poverty Level (per month: individuals
$1,805; couples $2,428), in addition their assets at or below the limit (individuals $4,000; couples $6,000).
Q.Hospice Care covers what services?
A.Individuals with a terminal illness have services
covered by Medicare Part A. These areas may include medical and support services from a Medicare-approved hospice, prescriptions
to control pain, as well as additional services, which normally are not covered by Medicare. Hospice can be received
by the individual in their home, while in a hospital (limited time) and respite care to give the main caregiver can
time off to rest.
Q.Tell me
about a Medicare Preferred Provider Organization (PPO) Plan?
A.A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing
a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician
to see a specialist. If you want the option to be able to see any provider within or outside of the network (for an
additional cost), then the PPO or Medicare Preferred Provider Organization Plan will suit you well. Any certain person will
not require any referral from a physician to see any specialist.
Q.What is a Medicare Managed Care Plan?
A.Medicare Managed Care Plans are optional in some areas of the country, the plans must cover all Part A and Part B
services and some may cover additional services such as prescription drugs. These plans are Medicare Advantage options that
may have lesser co-payments than the Original Medicare Plan but generally limits individuals to services inside the plan’s
networks such as primary doctors, specialists, and hospitals.
Q.Tell me about Medicare Advantage
A.Once known as Medicare Choice, Medicare Advantage is a program that gives benefits through private insurance companies.
It includes, Private Fee for Service, Managed Care or Medicare HMOs, Special Needs Plans, and Preferred Provider Organization.
These plans will give a larger spectrum of choice and other benefits. Everyone who has Medicare Parts A and B is eligible
to join a plan with the exception of most people with End-Stage Renal Disease (ESRD).
Q.Is a Skilled Nursing Facility Care (SNF) covered by Medicare?
Once the individual has been an inpatient for three consecutive days, the Skilled Nursing Facility Care
is covered by Medicare. This nursing care will include some or all of the following, rehabilitation care, the skilled nursing,
semiprivate private room and meals and any other service and supplies.
Q.What is a Medicare Private Fee-for-Service Plan?
A.A Medicare Private Fee for Service Plan allows that person to see any Medicare approved hospital
and or doctor and the insurance company determines what services it covers and what the associated costs are. This plan
could cost more but tends to offer extra benefits that Original Medicare doesn’t cover.
Q.When does a person qualify for a Medicare Special Needs Plan?
A.This is a Medicare Advantage plan that offers
health care based on certain diseases or conditions an individual has such as End-Stage Renal Disease (ESRD) and congestive
heart failure. This program is not offered in every part of the country.
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