NOTE: Ann Kasper, Program Director for HICAP (Health Insurance Counseling and Advocacy Program) in the Inland Empire, answers some very common questions about Medicare.
Q: I’m not 65, how would I get Medicare?
A: If you have a disabling condition serious enough that you can’t work and it is expected to be long-term or permanent, you may qualify for Social Security disability. You must have been in a Social Security covered job for at least 10 quarters out of the last 5 years. After 2 years on Social Security disability you automatically get Medicare coverage. (Editor’s Note: If you are eligible for Social Security disability and your application is denied appeal that decision. You must be your own advocate!)
Q: On my limited income, how much would I have to pay for Medicare?
A: Most people qualify for Medicare Part A (hospital insurance) automatically and pay nothing for it. Part B (outpatient expenses and doctor bills) cost $45.50 per month. For people who have low incomes (at the federally set poverty level of $716 for an individual or $958 for a couple per month), all Medicare expenses can be paid (even Part A if you don’t get it automatically). There are eligibility conditions, however.
Q: Does Medicare pay for all my health care costs?
A: There are quite a few health care costs Medicare doesn’t cover: Physical exams, most routine tests and screens, most dental work, outpatient prescription drugs, eyeglasses and hearing aids, routine custodial care in a skilled nursing home etc. That’s why most people secure something to supplement Medicare – Medi-Cal, an HMO, or a Medigap insurance policy, depending on your income and various other factors.
Q: If I don’t qualify for Medi-Cal (or don’t want it), what options do I have to Supplement Medicare and pay some of the other costs?
A: You can join one of the HMOs available in many parts of our two-county area. You need to learn about the HMO system to make a good choice. Next to Medi-Cal, this is the lowest cost option. You may want to check out Medigap policies. Read about this type of insurance in the literature from Social Security. Call HICAP [1 (800) 434-0222] for an unbiased explanation and then start calling insurance brokers. This option can be expensive, but very flexible. HICAP can give you more information.
Q: I don’t like the doctor I have, how can I get a new one? How do I know if my doctor is a good one or not?
A: In general, you can ask around and get names from people whose judgment you trust. If you’re on Medicare you can just call the new doctor’s office and ask if they are taking new patients and make an appointment if they are. If you are looking for a specialist, make sure he or she has the appropriate training and certification. In an HMO, ask around also for doctors other people have been satisfied with. If you have a serious chronic condition (in an HMO) you have the right to an appropriately trained specialist and treatment plan. Call member services or your case manager. Get things straightened out and set ahead of time, don’t just act.
Q: I’ve read the horror stories in the newspaper about HMO’s. After that I knew I didn’t want one of those. But when I checked out insurance policies to supplement Medicare in my age group, they were really expensive. What can I do? Where can I go?
A: If you’re on Medicare you have a lot of protection and rights that you don’t have on an employer’s plan. That definitely is true for HMOs. If you educate yourself on how the managed care system works, you can make it work for you – and at a far lower cost than Medicare and a supplemental. Call HICAP [1(800) 434-0222] for this kind of specific information and then make your own decision.
Q: I’ve got diabetes and I spend a lot of money every month on supplies. Is there any way to have them paid for?
A: Medicare now covers much of the cost for equipment and supplies for both Type I and Type II Diabetes. If you doctor or his nurse can’t give you more information you can call the 800 number for supplies and discuss the situation with them [1 (800) 899-7095]. Call HICAP [1 (800) 434-0222] if you don’t understand the terms used.
Q: What about prescription drugs – does anyone pay for them? I know the President is trying to get Medicare to include them, but that could be years away. What’s available here and now?
A: A new law in California allows all Medicare beneficiaries to buy their prescription drugs without limit at the same price as the state pays for Medi-Cal prescriptions. You must go to a pharmacy that has a Medi-Cal computer set up to get the prices for you. Some drugs will have a large discount, others will not. You can shop around because many pharmacies will be able to give you quotes.
Q: I haven’t been treated very well by my health insurance and I want to complain. How do I do that without making them mad at me?
A: HICAP counselors are there to help you file a grievance with the Department of Insurance (for regular Medigap policies) or with the HMO itself. After discussing how to do it, you may want to carry it through yourself.
Q: I’ve had trouble with durable medical equipment (DME). How can I judge a supplier?
A: You need to ask some questions before you contract with a supplier. First, find out if the company accepts Assignment. This is important because you will not have to pay anything "up front" if they do. You also need to ask for a copy of the Supplier Standards (issued by the National Supplier Clearinghouse) available from any DME supplier who contracts with Medicare. Read them and be sure you are getting equipment and service that meets those standards. Keep your copies of all delivery and pick-up slips to document how long you have had the equipment and when you returned or discarded it. Fraud and abuse are fairly common with this type of medical equipment, so be sure you are getting what you need and what Medicare is paying for. Be wary of products or services that are free, but ask for your Medicare or HMO card. Call HICAP or Medicare if you are suspicious.
Q: I already have Medi-Cal, why would I want Medicare?
A: Medicare becomes your primary (first) payer of medical costs and Medi-Cal will be secondary, paying any out-of-pocket Medicare expenses and covering some things Medicare doesn’t. If you qualify, it will save you money in the long run.
Q: My doctor doesn’t look or talk to me when I go for an office visit. Instead he talks to my daughter, who helps me. How can I get the doctor’s attention without embarrassment?
A: The obvious suggestion would be to have your daughter leave you alone in the examining room. Or, after realizing that doctors are just people, tell the doctor in a pleasant tone that you would appreciate his/her talking directly to you. The doctor will then be the embarrassed one.
If you have a question about your insurance – what is or is not covered E-Mail it today .
Return to Text Only Understanding Medicare Index
Go to the Vital Connections' Front Page