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Health and Insurance

Medicare

Medicare insurance is generally available to the following: Individuals 65 or older, if they are eligible for, or are receiving, Social Security or Railroad Retirement benefits; individuals (any age) who have received Social Security disability benefits for at least 24 months; individuals (any age) who have permanent kidney failure; and certain government employees whose work has been covered for Medicare purposes. Contact should be made with Social Security (1-800-772-1213, www.ssa.gov) to obtain further information regarding eligibility and enrollment.

Medicare Options - When you are eligible for Medicare, you will be in Original Medicare unless you choose one of the other Medicare options. In New Jersey you have options on how you receive your Medicare coverage: Original Medicare, Medicare Advantage Health Maintenance Organization, Medicare Advantage Preferred Provider Organization – PPO (Point of Service – POS), Medicare Advantage Private Fee-For-Service Plan (PFFS), Medicare Advantage Special Needs Plan (SNP) or Medicare Advantage Medical Saving Account (MSA) Plan. No matter which option you choose, you have Medicare.

Original Medicare - Under Original Medicare beneficiaries receive health benefits under Part A (hospital insurance) and Part B (medical insurance). They generally can go to any doctor, specialist or any hospital that accepts Medicare patients. You must pay a monthly Part B premium which is usually taken out of your monthly retirement payment. You are also responsible for a Part A deductible, and a Part B deductible before Medicare begins to pay. After Medicare pays 80% of the allowed amount for covered medical services, you will also be responsible for a 20% coinsurance.

Medigap is private insurance that is designed to help pay deductibles and coinsurance amounts for Original Medicare - Parts A and B. These policies are also called supplement policies and only work with Original Medicare. You will have to pay a premium for your Medigap policy and you must continue to pay the monthly Part B premium. There are 12 standard Medigap policies and each offers a different combination of benefits that fill different gaps in Original Medicare. The benefits for each plan are the same no matter which company offers them. For a period of six months from the date you are first enrolled in Medicare Part B and are age 65 or older, you have a right to buy the Medigap policy of your choice. Once this Medigap "open enrollment" period ends, you may not be able to buy the policy of your choice. Medigap supplement policies are "guaranteed renewable". The policy cannot be cancelled or non-renewed for any reason except non-payment of premium.

Medicare Enrollment Periods - The changes an individual can make to their Medicare coverage depends on the enrollment period.

Annual Enrollment Period (AEP) - allows individuals to join or leave a Medicare Advantage Plan, switch to Original Medicare, or join or leave a Medicare prescription drug plan.

Medicare Advantage Open Enrollment Period (OEP) - occurs from January 1 through March 31 every year.  Enrollees can join a new plan, switch plans, or return to Original Medicare.  The changes made during this period will be effective the first day of the month after the plan gets the person’s enrollment form.  The OEP can be used to switch to a different plan or type of plan, but it cannot be used to change whether or not a person is enrolled in Medicare prescription drug coverage.

Special Enrollment Period - is for people who have joined a MA plan for the first time and allows them to drop their MA plan and enroll in Original Medicare anytime within the first 12 months of their MA plan coverage.  They also have a guaranteed issue opportunity to purchase a Medigap (Medicare supplement) policy.

Annual Election Period - is also referred to as the Medicare fall open enrollment period from November15 – December 31.  People can make changes in their plan enrollment, including choosing which Medicare Advantage Plan or Medicare Prescription Drug Plan they want to join for the upcoming year.  They can also choose to return to Original Medicare.  Their new plan will start the following January 1.

Medicare Hospital Insurance Program (Part A)

Medicare Part A, the premium free Hospital Insurance Program, helps pay for four kinds of medically necessary care: (1) inpatient hospital care; (2) some inpatient care in a skilled nursing facility following a hospital stay; (3) home health care; and (4) hospice care. Part A is free for most people.

Hospital Premium - Premium-free Medicare Hospital Insurance (Part A) is generally available to individuals who are eligible for Medicare. Individuals age 65 and older who are U.S. citizens and residents and who have not worked long enough to qualify for premium-free Part A may buy Medicare coverage. There is a monthly premium and possibly a surcharge for late enrollment. Aliens 65 or over who are US residents and who have been lawfully admitted for permanent residence and have resided in the US for at least five years at the time of filing may also be eligible to purchase both Part A and Part B, or just Part B. If you are not sure you qualify for premium-free Part A, you should contact your local Social Security Office, or call Social Security at 1-800-772-1213 or visit the Medicare website at www.medicare.gov regarding your eligibility to enroll and the amount of the monthly premium for Part A coverage that you would be required to pay.

Benefit Periods - When if you are admitted to a hospital or skilled nursing facility, Medicare Part A pays benefits based on benefit periods. A benefit period begins the first day you receive a Medicare covered service in a hospital or skilled nursing facility (SNF) and ends when you have been out of a hospital or SNF for 60 consecutive days. If you enter a hospital or SNF again after 60 days, a new benefit period begins. All Part A benefits, except for any lifetime reserve days used, are renewed.

Inpatient Hospital Deductible/Co-Payments - Part A pays for all covered services for the first 60 days of inpatient hospital care in a benefit period, except for the Part A deductible. For the 61st-90th day, Part A pays for all covered services except for the per day coinsurance. Every person enrolled in Part A also has a lifetime reserve of 60 days for inpatient hospital care. These days may be used whenever more than 90 days of inpatient hospital care are needed in a benefit period. While reserve days are being used, Part A pays for all covered services except for a per day coinsurance for each "reserve day." Once used, reserve days are not renewable. Deductibles/co-insurance amounts change annually.

Skilled Nursing Facility Care - Medicare Part A can help pay for medically necessary inpatient care in a Medicare-participating skilled nursing facility following a minimum three-day hospital stay. If your stay in a skilled nursing facility is covered by Medicare, Part A helps pay for a maximum of 100 days in each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. Very specific conditions must be met for you to qualify for skilled nursing facility care. Any service that could be safely performed by an average non-medical person (or one's self) without the direct supervision of a licensed health care professional is not covered. In each benefit period, Part A pays for all covered services for the first 20 days you are in a skilled nursing facility. Part A pays for all covered services except for the per day coinsurance for days 21 through 100 which is the responsibility of the beneficiary. If you have questions about what specific conditions must be met for you to qualify for skilled care, please contact Medicare toll-free at 1-800-Medicare (1-800-633-4227).

Home Health Care - Part A pays the approved cost of medically necessary home health visits for homebound beneficiaries following at least a 3-day hospital stay. Coverage includes the intermittent services of a skilled nurse and the services of physical, occupational and speech-language therapists when furnished through a Medicare-certified home health agency. Part A can also cover reasonable and necessary part-time or intermittent home health aide, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) provided under a plan of care established and periodically reviewed by a physician. Part A does not cover full-time nursing care, drugs, meals delivered to your home or homemaker services that are primarily to assist you in meeting personal care or housekeeping needs. Medicare beneficiaries may occasionally leave their home for special non-medical events for brief periods of time without risking termination of their home health benefits coverage. If you have questions about home health care and conditions of coverage, or to order a pamphlet on this topic, call Medicare toll-free at 1-800-Medicare (1-800-633-4227).

Hospice Care - Medicare beneficiaries certified as terminally ill may elect to receive hospice care under Part A instead of regular Medicare. Part A can pay for medical and support services from a Medicare-approved hospice, drugs for symptom control and pain relief, short-term respite care, care in a hospice facility, hospital, or nursing home when necessary, home care and other services not otherwise covered by Medicare. You must meet certain conditions to qualify for this service. If you have questions about this service, or to order a pamphlet on this topic, call Medicare toll-free at 1-800-Medicare (1-800-633-4227).

Patients' Rights, HQSI, Quality of Care Complaints - Medicare requires that hospitals supply a statement of patients' rights to Medicare beneficiaries the day they enter the hospital. In addition, Medicare contracts with Healthcare Quality Strategies, Inc. (HQSI), an independent physician group, to ensure that the beneficiaries receive the best medical care possible. HQSI offers review of appeals of non-coverage during the hospital stay, and responds to written complaints concerning quality of care received. Quality of care complaints must be from Medicare beneficiaries treated in a facility certified by Medicare, and the services received must be services that normally would be covered by Medicare. (NOTE: Complaints about quality of care include treatment as an inpatient/outpatient in a hospital, or provision of services of a skilled nursing facility, home health agency, or ambulatory surgical center).

Hospital Discharge - You have the right to get all of the hospital care that you need, and any follow-up care after you leave the hospital. Before discharge from the hospital, Medicare patients should request a Discharge Plan from their doctor or hospital social worker. This plan will specify the proper post-hospital care and treatment. Medicare patients who feel that the Discharge Plan is unsatisfactory may request to have their case reviewed by Healthcare Quality Strategies, Inc. (HQSI).

Information, Complaints - For more information concerning rights of beneficiaries under Medicare Part A, contact HQSI during business hours at 1-800-624-4557 or 732-238-5570, www.pronj.org/index.php. To file a complaint concerning quality of care, write Healthcare Quality Strategies, Inc., 557 Cranbury Road, Suite 21, East Brunswick, NJ 08816-4026.

Medicare Medical Insurance Program (Part B)

Medicare Part B medical insurance helps pay for (1) doctor's services; (2) in/outpatient medical and surgical services and supplies; (3) physical, occupational and speech therapy; (4) diagnostic tests; (5) durable medical equipment; (6) ambulance services; (7) clinical laboratory services (blood tests, urinalysis); (8) home health care when Part A doesn't pay and; (9) other health services and supplies which are not covered by Medicare Hospital Insurance. A monthly premium is charged. Under certain conditions, if you do not enroll for Part B when you are first eligible, you will not be able to enroll until a general enrollment period and you may have to pay a higher monthly premium for delaying enrollment.

Deductible/Limiting Charge - Medicare pays for some of your health care, but not all of it. When you receive health care services, you will have to pay deductibles and coinsurance or copayments. You must pay a deductible before Medicare will pay its share. If a doctor or supplier does not accept the amount Medicare pays for most covered services, there are limits on the amount that can be charged. The most the doctor or supplier can charge you is 15 percent more than the Medicare-approved amount.

Medicare Mental Health Services - Medicare’s outpatient mental health services coinsurance rate of 50% is being gradually reduced to 20%, the same rate that applies to other types of outpatient medical care. The coinsurance rates of 20% is being phased in over a six-year period beginning in 2008.

Transplant Services - Under certain conditions Medicare benefits helps pay for immunosuppressive drugs prescribed following organ transplants and certain oral cancer drugs. Chemotherapy for the treatment of disease by means of chemical substances or drugs is also covered. You will need both Part A and Part B in order for Medicare to cover certain dialysis and kidney transplant services.

Medicare Prescription Drug Coverage (Part D) - A new federal program offering prescription drug coverage for Medicare beneficiaries began on January 1, 2006. The Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. This coverage is provided by private companies whose plans are approved by Medicare. Brand-name and generic prescription drugs are covered through participating pharmacies.

In the past, many people could not get Medicare coverage for certain anticancer chemotherapeutic drug regimens because of limitations on what were considered acceptable uses. In January 2009 Medicare began accepting drugs taken for an off-label use, if they have been included in approved “compendia” (dictionaries of drugs and their officially recognized uses) and other peer review medical literature.

Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now.

  • You must be enrolled in Medicare Part B.
  • You must sign up when you are first eligible or you may pay a penalty.
  • To get Medicare prescription drug coverage you can join a Medicare prescription drug plan, you can join a Medicare Advantage Plan or other Medicare Health Plans that offer drug coverage.
  • There are no restrictions due to income and resources, health status, or current prescription expenses.
  • If you join, you will pay a monthly premium.
  • You may be required to pay a yearly deductible, a part of the cost of your prescriptions, a co-payment or coinsurance.
  • If you have limited income and resources you may qualify for support services from the New Jersey Department of Health & Senior Services.

Even if you don't use a lot of prescription drugs now, you should still consider enrolling in a Medicare prescription drug plan. For most people, joining now means protecting yourself from unexpected prescription drug bills in the future.

Medicare Prescription Drug Coverage Gap - Most Medicare prescription drug plans (Part D) have an initial coverage level. You pay co-payments or coinsurance until your drug costs reach the level limit on what they will cover. Once you reach your plan’s coverage gap, known as the “doughnut hole,” the plan pays no benefit; you pay all of your drug costs. In the gap your expense may be several thousand dollars. Most of the Medicare drug plans provide coverage if you have an unexpected illness or injury that results in extremely high drug costs (called catastrophic coverage). Once you have paid the out-of-pocket for drug costs in a calendar year, your drug costs above that amount may be covered.

Here are some ways you can avoid or delay entering the gap, and continue to save money on drug costs while in the gap:

  • Consider switching to generic, over-the-counter (OTC), or other lower-cost drugs that can save you hundreds or thousands of dollars a year.
  • Use mail-order pharmacies, generic, or less-expensive brand-name drugs.
  • Always use your drug plan card – even in the gap. This ensures that you’ll get the drug plan’s discounted rates and that the money you spend counts toward your catastrophic coverage.
  • Rx4NJ offers comprehensive information on help for free or nearly-free prescriptions through existing patient assistance programs. For more information on this program call 1-888-793-6765 or go to www.rx4nj.org.
  • If you have limited income and resources, you may qualify for extra help paying for your prescription drugs.

Contact Social Security by calling 1-800-772-1213. TTY users should call 1-800-325-0778 or visit www.socialsecurity.gov or you can call your State Health Insurance Assistance Program (SHIP) at 1-800-792-8820.

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Medicare Extended Coverage

Airway Pressure Device - Medicare Medical Insurance will routinely cover continuous positive airway pressure devices (nose masks) used to help control sleep apena, a condition that causes some people to stop breathing for brief periods during sleep.

Ambulatory Blood Pressure Monitoring - Medicare will cover this system of blood pressure monitoring which involves wearing a cuff that automatically records blood pressure over a 24-hour period. Targeted specifically are those patients with "white coat hypertension", a term meaning that just going into a doctor's office is enough to raise their blood pressure. Medicare does not cover the purchase of this item for private uses.

Chiropractic Coverage - Medicare Medical Insurance will cover manual chiropractic manipulation of the spine and/or physiological function of the spine.

Eyeglasses - Medicare Medical Insurance can help pay for your first pair of glasses after cataract surgery. Medicare may also cover some types of tints and coatings if your doctor prescribes them. The supplier will submit the claim to Medicare.

Foot Care - Medicare Part B Medical Insurance will cover regular foot care once every six months for diabetic patients with peripheral neuropathy, a nerve condition that lessens their ability to feel pain.

Therapeutic Footwear - Medicare Medical Insurance helps pay for fitting and for the cost of one therapeutic pair of shoes and shoe inserts in a calendar year for beneficiaries who have severe diabetic disease. The doctor treating the beneficiary under a comprehensive diabetic care plan must certify the need for the shoes or inserts.

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Medicare Preventive Services

Abdominal Aortic Aneurysm (AAA) Screening - Medicare covers this one-time screening ultrasound if you get a referral for it as a result of your "Welcome to Medicare" physical exam. You must receive the physical exam and the screening ultrasound referral (not the ultrasound exam itself) within the first six months you have Medicare Part B. For the AAA screening ultrasound, you pay 20 percent of the Medicare-approved amount with no Part B deductible.

Cardiovascular Disease Screening Blood Tests - Medicare will cover blood tests every five years to screen for cholesterol, lipid and triglyceride levels. Medicare will pay 100 percent of its approved amount for these tests, even if you have not yet met the Part B deductible.

Colorectal Cancer Screening - Medicare Part B covers an annual screening fecal occult blood test; a flexible sigmoidoscopy once every 4 years, and a colonoscopy every 10 years for people not at high risk for colorectal cancer and every 2 years if you are at high risk for colorectal cancer or a barium enema as an alternative. You pay nothing for the fecal occult blood test. For all other screening tests (i.e. sigmoidoscopy and colonoscopy), the coinsurance or copayment applies, but the Medicare Part B deductible is waived.

Diabetes Education - Medicare Part B covers a wider range of education and training to teach diabetics to control their blood glucose levels.

Diabetes Glucose Monitoring - All Medicare beneficiaries with diabetes have coverage for blood glucose monitors, lancets and testing strips. These benefits are subject to the Medicare Part B deductible and coinsurance. Every 12 months Medicare will cover the laboratory tests to screen high-risk individuals for diabetes.

Glaucoma Screening - Medicare Part B covers an annual dilated eye examination for all people with Medicare at high risk for glaucoma. This includes people with diabetes or a family history of glaucoma. A licensed eye doctor must provide the screening. Medicare covers 80% of the Medicare-approved amount for glaucoma screening after the individual has paid the deductible for Part B services.

Bone Mass Measurement - Medicare will provide one bone mass measurement every two years (24 months) for beneficiaries at risk for osteoporosis and other bone abnormalities. These tests will help to identify bone mass, detect bone loss, or determine bone quality. The tests are subject to the Part B deductible and coinsurance.

Preventive Physical Examination - Medicare will cover a one-time initial wellness ("Welcome to Medicare") physical preventive exam in the first 12 months after a person enrolls in Part B of Medicare. Medicare will pay 80 percent of the Medicare-approved amount after you pay your Part B deductible. Medicare will not cover routine physicals.

Hepatitis B Vaccine - Medicare Part B helps pay for Hepatitis B vaccine administered to beneficiaries considered to be at high or intermediate risk of contracting the disease. A Medicare certified provider must administer the vaccine. This coverage is subject to regular Medicare Part B deductible and coinsurance provisions.

Influenza Virus Vaccine - Medicare Part B will cover an influenza virus vaccine and its administration. Generally, only one influenza virus vaccination is medically necessary per year. Payment for the "Flu Shot" and its administration is at 100% of the Medicare allowed amount when given by doctors who accept Medicare assignment.

Pneumococcal Vaccine - Medicare Part B pays the full-approved charges for pneumococcal vaccine and its administration. A Medicare certified physician must administer the vaccine. No Medicare deductible or coinsurance is applicable.

Shingles Vaccine - Shingles, also called herpes zoster or zoster, is a painful skin rash caused by the varicella zoster virus. This illness is vaccine-preventable. This vaccine reduces the risk of Shingles in people ages 60 and older. The vaccine will be reimbursed through the Medicare Part D (Prescription Drug) program. Beneficiaries should contact their Part D plan for more information.

"Pap Smear" Screening - Medicare Part B pays for "pap smear" screenings and related medically necessary physician services (including a physician's interpretation of the results of the tests) for female Medicare beneficiaries. Medicare pays for one screening every two years, or more frequently for women at high risk of uterine or vaginal cancers. The Part B deductible is waived but the service is subject to the 20% co-pay.

Prostate Cancer Screening - Medicare Part B will cover annual preventive screenings for prostate cancer for Medicare eligible men age 50 and older. This will include the prostate specific antigen (PSA) test as well as the digital rectal exam. Medicare will pay 100% of the Medicare-approved amount for the PSA test and 80% of the Medicare-approved amount for the digital rectal examination after the annual Medicare Part B deductible is met.

Mammogram - Medicare Part B Insurance helps pay for annual breast examinations, x-ray screenings, and new digital technologies for mammogram screenings. For Medicare-eligible women aged 35 – 39 Medicare pays for a baseline mammogram. For Medicare-eligible women aged 40 and older Medicare pays for an annual mammogram. The Part B deductible is waived, but the 20% co-pay applies. Medicare also pays for diagnostic mammograms as needed when symptoms are present.



Medical Nutrition Therapy - Medicare Part B will cover medical nutrition therapy for people with diabetes, chronic renal disease (but not on dialysis), and post- transplant patients when referred by a doctor. The services must be provided by registered dieticians or other qualified nutrition professionals. Medical nutrition services include nutritional assessment and counseling; an initial visit for an assessment; and follow-up visit for interventions and reassessments to assure compliance with the dietary plan. Medicare covers 80% of the Medicare-approved amount for Medical Nutrition Therapy after the individual has paid the deductible for Part B services.

Smoking Cessation (Counseling to quit smoking) - People with Medicare who are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco are covered for up to eight counseling visits during a 12-month period. Medicare will pay 80 percent of the Medicare-approved amount after you pay the Part B deductible.

Durable Medical Equipment/Supplies - Under very specific guidelines, Medicare Part B helps pay for medically necessary equipment that your doctor prescribes for use in your home, such as oxygen equipment, wheelchairs and hospital beds. Certain medical supplies are also covered. Your supplier must have a Medicare approved number.

If you have any questions about claims or payments relating to durable medical equipment or supplies telephone toll-free 1-800-Medicare (1-800-633-4227).

Medicare Part A and Part B Carriers - Medicare is replacing its current private claims payment contractors for Medicare Part A and Medicare Part B fiscal intermediaries with entities called Medicare Administrative Contractors (MACs) except for Railroad Retirement retirees.  Railroad Retirement beneficiaries entitled to Medicare, physicians and other suppliers (except for DMEPOS suppliers) will continue to enroll with and bill the contractor designated by the Railroad Retirement Board for Part B services furnished to these beneficiaries.  The MAC’s will handle major business functions of contractors such as - Claims Processing, Beneficiary and Provider Customer Service, Appeals, Provider Education, Financial Management, Provider Enrollment, Reimbursement, Payment Safeguards and Information Systems Security.

For Medicare Part B carrier information the toll-free telephone number is 1‑800‑Medicare (1-800-633-4227).  The toll-free telephone for Railroad Retirement Medicare information is 1-800-833-4455 or 1-800-808-0772.  More descriptions of services covered under Part B can be found in the MEDICARE AND YOU publication.

Electronic Handbook (eHandbook) - You can now choose to receive the annual “Medicare & You” handbook electronically (also called the eHandbook).  Save tax dollars by signing up to access future handbooks electronically.  Visit www.MyMedicare.gov or telephone toll-free 1‑800‑Medicare (1-800-633-4227) to request the eHandbook for 2010.  You will not receive a copy of the handbook by mail if you select to receive it electronically.

Non-Covered Services Medicare Part A and Part B Services - Medicare does not cover everything.  In addition to your premiums, deductibles and coinsurance, Medicare does not cover:

  • routine dental care and dentures
  • custodial care (help with bathing, dressing, toileting and eating)
  • cosmetic surgery, wigs, hearing aids and routine eye care
  • routine foot care and orthopedic shoes
  • routine physical exams and acupuncture
  • most health care outside the United States and its territories

Advance Beneficiary Notice (ABN) - Medical providers and suppliers are required to give you an Advance Beneficiary Notice (ABN) with estimated cost when they offer you service or items that they know or have reason to believe Medicare will not pay for.  You should always choose that your doctor submit the claim to Medicare because Medicare may pay for the services, even if it seems unlikely and you will also have the option to appeal.

Medicare Part B Carrier - A private insurance company contracts with Medicare to process beneficiary claims, except for Railroad Retirement retirees. For Medicare Part B carrier information the toll-free telephone number is 1-800-Medicare (1-800-633-4227). The toll-free telephone for Railroad Retirement Medicare information is 1-800-833-4455 or 1-800-808-0772. More descriptions of services covered under Part B can be found in the MEDICARE AND YOU publication.

Non-Covered Services Medicare Part A and Part B Services - Medicare does not cover everything. In addition to your premiums, deductibles, and coinsurance, Medicare does not cover:

  • routine dental care and dentures
  • cosmetic surgery, wigs, hearing aids and routine eye care
  • custodial care (help with bathing, dressing, toileting and eating)
  • routine foot care and orthopedic shoes
  • routine physical exams and acupuncture
  • most health care outside the United States and its territories

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Medicare Advantage Program (Part C)

The Medicare Advantage program allows beneficiaries to choose to receive their Medicare benefits through a variety of other health delivery options: health maintenance organizations (HMOs), with or without a point of service option, preferred provider organizations (PPOs), provider sponsored organizations (PSOs), private fee-for-service plans (PFFS), medical savings accounts (MSAs), or special needs plans (SNPs). Medicare Advantage plans must provide the same services and benefits (other than hospice care) as are covered under Original Medicare. For information about availability in your area, you may call toll-free 1-800-Medicare (1-800-633-4227).

To be eligible for Medicare Advantage health plans:

  • You must have Part A (Hospital Insurance)
  • You must have Part B (Medical Insurance)
  • You must not have End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant)
  • You must live in the geographic and service area where the plan accepts enrollees

Your out-of-pocket costs may depend on:

  • Which Medicare health plan you choose
  • How often you need health care
  • What type of health care you need
  • Which extra benefits are covered by the plan

CAUTION: Changing the way you receive your health care is an important decision and should be reviewed carefully before determining which new choices may be right for you. Remember: you do not have to change from Original Medicare.

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Medicare Advantage Program Plans

Medicare Advantage Managed Care Plans - Managed care plans provide all of Medicare's benefits and frequently more. They have agreed to provide care to beneficiaries in exchange for a predetermined amount of money from Medicare every month. The managed care plans provide most of Medicare's benefits through a network of doctors and hospitals on an approved list. You generally must receive all covered care through the plan or from health care professionals to whom the plan refers you. Some plans may offer supplemental benefits for which you pay a separate premium. Services may be obtained outside the network if you are willing to pay extra. If you receive services not authorized by the plan, neither the plan nor Medicare will pay.

Medicare Advantage Health Maintenance Organization (HMO) - An HMO involves a group of doctors, hospitals, and other health care providers who have agreed to treat members of the plan. The plans have lock-in requirements. This means you generally receive all covered care through the plan's network of doctors and hospitals. In most cases, if you receive services not authorized by the plan, neither the plan nor Medicare will pay.

Medicare Advantage Preferred-Provider Organization (PPO) (also referred to as Point of Service Plan - POS) - A PPO is a type of managed care plan that allows the beneficiaries to use any doctors or hospitals and other providers who are reimbursed on a fee-for-service basis. The insurance plan decides how much to reimburse for the services you receive. Providers may bill more than the plan pays and you will be responsible for paying the difference. Fees charged will be less if use is limited to approved providers.

Provider-Sponsored Organization (PSO) - PSOs are owned and operated by doctors, hospitals or an affiliated group of health care providers that provide a substantial portion of health services to beneficiaries. You must use the plan's doctors, hospitals and affiliated providers.

Religious Fraternal Benefit Society Plans (RFBS) - RFBS plans are offered by a Religious Fraternal Benefit Society that may restrict enrollment to members of the group with which the society is affiliated.


Private Fee-For-Service Plan (PFFS) - A Private Fee-For-Service plan is a Medicare health plan offered by a private insurance company. In a Private Fee-For-Service plan, Medicare pays a set amount of money every month to the private company to provide health care coverage to people with Medicare on a pay-per-visit arrangement.

Each year, the insurance companies offering Private Fee-For-Service plans can decide to join or leave Medicare.

  • In Private Fee-For-Service plans, you may go to any doctor or hospital
  • You can get services outside your service area
  • You get all services covered under Medicare Part A and Part B
  • You may have extra benefits the Medicare Plan does not cover, like outpatient prescription drugs, but you may have to pay more for these extra benefits
  • Private Fee-For-Service plans can charge you a premium amount above the Medicare Part B premium
  • Private Fee-For-Service plans can charge deductible and coinsurance amounts that are different than those under the Original Medicare Plan

Private Fee-For-Service plans may let providers charge you 15% over the plan's payment amount for services. This 15% balance billing amount applies to providers who have a written contract with the Private Fee-For-Service Plan or who the company has decided to think of as having a contract because they have met certain conditions. If the provider does not have a contract with the Private Fee-For-Service plan, or is not deemed to have a contract with the plan, the provider cannot charge you more than the plan's cost sharing amount. Because this could affect how much you will pay for services, find out if your Private Fee-For-Service plan allows balance billing and what other costs you may have. Even if balance billing is allowed, your provider may be willing to accept the plan's payment in full.

Note: The insurance company, rather than the Medicare Program, decides how much you pay for the services you get.

Medicare Advantage Special Needs Plan (SNP) - A SNP is a special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid/NJ FamilyCare, those who reside in a nursing home, or those who have certain chronic medical conditions.  New guidelines that take affect in 2010 identify 15 specific chronic conditions defined as severe or disabling that will dictate eligibility for a Chronic Care Medicare Advantage Special Needs Plan.  The conditions include dementia, chronic heart failure, diabetes mellitus, and stroke.

Medicare Advantage Medical Savings Account (MSA) - MSA Plans combine a high deductible Medicare Advantage Plan (like an HOM or PPO) with a Medical Savings Account for medical expenses. A Medicare MSA Plan has two parts. One part is the Medicare MSA, a special type of savings account. We will call this the "Account." The Account holds money for you to use to pay your medical bills. The money in your Account is not taxed if it is used for qualified medical expenses, and it may earn interest or dividends.

The other part of a Medicare MSA Plan is the Medicare MSA Health Policy. We will call this the "Policy." This is a special health insurance policy that has a high annual deductible. You choose the Policy you want to use as part of your Medicare MSA Plan. The Medicare program must have approved this Policy. An insurance company offers the Policy to you, and it must be designed to work as part of a Medicare MSA Plan. You also choose the bank or other institution where your Account is set up. The bank or institution (called a trustee or custodian of your Account) must be registered with the Medicare program to set up Medicare MSAs. When you have chosen a policy and set up your Account, your Medicare MSA Plan is complete and ready to work.

You enroll in a Medicare MSA Plan for a year, January through December. At the beginning of the year, the Medicare program makes a deposit in your Account for the entire year. You can use that money to pay for your health care. Every month, the Medicare program (not you) pays a premium for your Policy to the insurance company. Your Policy must offer all Medicare covered benefits. Some Policies may cover additional benefits. If you meet your Policy's deductible, your Policy coverage begins and helps you pay your bills after that (for benefits that the Policy covers). You may be able to choose any doctor or provider for your medical care, or your Policy may limit your choice of doctors and other providers depending on the Policy you choose.

Medicare Advantage Special Needs Plan (SNP) - A SNP is a special type of Medicare Advantage Plan that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid/NJ FamilyCare, those who reside in a nursing home, or those who have certain chronic medical conditions.  New guidelines that take affect in 2010 identify 15 specific chronic conditions defined as severe or disabling that will dictate eligibility for a Chronic Care Medicare Advantage Special Needs Plan.  The conditions include dementia, chronic heart failure, diabetes mellitus, and stroke.

Medicare as Secondary Payer

Medicare has special rules that apply to beneficiaries who have employer group health plan coverage through their employment or the employment of a spouse or civil union partner. Some employer and union-provided health insurance policies can continue or switch over to provide coverage for you when you are 65 and retired. If you accept your employer's health plan, it will pay first on your health claims; Medicare will become the secondary payer. If you reject your employer's health plan, Medicare will remain the primary health insurance payer. If you elect Medicare to be the primary payer, your employer plan cannot offer you coverage that supplements Medicare. Contact your former employer or union for information on your plan. If your employer denies you coverage or pays benefits that are secondary to Medicare, call 1-800-MEDICARE (1-800-633-4227).

Original Medicare Appeals - If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you received, you have the right to appeal the decision. The notice you receive from Medicare tells you the decision made on the disputed claims and also tells you exactly what appeal steps you can take. If you ever need more information about your right to appeal and how to request it, call Social Security or Medicare at 1-800-Medicare (1-800-633-4227). Your Area Agency on Aging or State Health Insurance Assistance Program (SHIP) can also offer direction.

Medicare Fraud and Abuse - The majority of physicians, providers, and suppliers who serve people with Medicare provide high quality care to their patients and bill the program only for the payments they have earned.  There are a few individuals who may attempt to defraud (cheat) Medicare.

Medicare Marketing Fraud – Medicare’s open enrollment period is the time when people with Medicare can enroll in, disenroll from, or switch to another Medicare private health plan or change to Original Medicare.  You should be aware that your Medicare benefits change each year and it is important to review your Medicare coverage to make sure that it will still cover your health care needs at a cost you can afford.  During this time period, the insurance companies may attempt to enroll people with Medicare into their health plans.  To increase the probability of getting people interested in their plans, a salesperson may repeatedly make contact (phone or in person) or overstate the benefits of their product.  This increased enrollment activity can mean an increase in deceptive enrollment practices, called marketing fraud.

If you were provided incorrect information unintentionally or based on incorrect or misleading information, or were kept in or enrolled in a plan you did not want, there are a few actions you can take to repair the situation and get out of the plan.

  • Retroactive disenrollment – You will be able to enroll in a new private health plan or Original Medicare. The new plan will pay claims for costs incurred while enrolled in the plan. The providers must resubmit the bills.
  • Prospective disenrollment - If you did not incur a lot of costs or your claims were not denied, it may be better to disenroll from the plan at the beginning of the next month, but you will have to pay any costs incurred while you were in the plan.
  • Special enrollment period (SEP) – If you are the victim of marketing fraud, the SEP will entitle you to change plans outside of the official annual enrollment periods. You could switch into another Medicare private health plan that better fits your needs or back to Original Medicare.
  • To get a prospective or retroactive disenrollment, you will need to prove a “lack of intent” to enroll. Evidence of “lack of intent” may include:
    • A legal representative should have signed for you
    • You requested a cancellation of enrollment before the effective date of enrollment in the plan
    • You were enrolled in a supplemental insurance plan (Medigap) after enrolling in a private health plan.

For further information on marketing fraud or to disenroll you should call 1-800-MEDICARE (1-800-633-4227).

Identity Theft – Identity theft is a serious crime.  Identity theft happens what someone uses your personal information without your consent to commit fraud or other crimes.  Personal information includes things like your name and your Social Security, Medicare or credit card numbers.  Guard against identity theft by taking action to protect yourself.  Here are some tips to help you protect your identity:

  • Don't carry your Social Security number in your wallet and carry only needed credit cards.
  • Shred all pre-approved credit offers, bank statements and utility bills before putting them in the trash.
  • Never give out personal information or a Social Security number over the phone, in-store or online unless you know the company.
  • Check bank and credit card accounts regularly and credit scores at least once a year.

Keep your personal Information safe. No one should call you or come to your home uninvited selling Medicare products. You have control over when you provide and who you allow to have your personal information.

Note: Medicare demonstrations or pilot programs are allowed to call you to ask if you want to enroll. Call 1-800-MEDICARE (1-800-633-4227) to report any plans that asks for your personal information over the telephone or that call to enroll you in a plan.

Senior Medicare Patrol (SMP of NJ) – SMP of NJ is a program that identifies and reports health care waste, fraud and abuse. Volunteers are trained to work in their communities to help identify deceptive health care practices, such as overbilling, overcharging, or providing unnecessary or inappropriate services. If you suspect other than proper billing has been provided for services rendered to you, please call 1-877-678-4697or 1-732-777-1940.

Planning Ahead

Long-Term Care Insurance – Medicare and most health insurance plans, including Medigap (Medicare Supplement insurance) policies do not cover long-term care (“custodial care”). Medicare only pays for medically necessary skilled nursing facility or home health care if you meet certain conditions.

Long-term care insurance is private insurance purchased to help pay for many types of long-term care (skilled and non-skilled, in-home and in long-term care facilities). This insurance provides a variety of services including medical and non-medical care for people who have a chronic illness or disability. If you are considering buying a policy, look for one that covers a range of services including informal home care, medical equipment, adult day health services (day care), assisted living and nursing home care.

Note: Long-term care insurance does not replace your Medicare coverage.

For information on Long Term Care Insurance, please contact the NJ Department of Health and Senior Services, Division of Aging and Community Services, telephone, toll-free, 1-800-792-8820 or 609-943-3437.

Qualities of Plans and Providers (Compare) – Medicare collects information about the quality of care and services given by most Medicare plans and other health care providers, as well as information about how satisfied people are with the care and service they get. You can compare the quality of care and services given by health and prescription drug plans or health care providers by visiting www.medicare.gov or by calling your State Health Insurance Assistance Program (SHIP) 1-800-792-8820.

Health Records – Electronic and Personal – Many health care providers, like doctors, nurses, hospitals and equipment suppliers, are starting to keep your information in a computer instead of writing the information in a paper chart. Two types of health records are stored electronically. Electronic Health Records (EHRs) are records that your doctor, your doctor’s staff, or a hospital keeps with information about your health and medical treatment (like lab reports). Personal Health Records (PHRs) are records you keep or control to track information like the date of your last physical, test results, illnesses, allergies and medications. Over time, these electronic records will help providers have the same knowledge about your condition, treatments, tests, and prescriptions, which lowers the chances of medical errors and can help improve your overall quality of care. Federal and state governments have strict rules about protecting the privacy and security of this electronic information.

For more information about EHRs and PHRs visit www.medicare.gov.

Medicare Savings Programs The Medicare Savings Program may help pay part of your medical expenses. If you qualify, you may not have to pay your Medicare Part A and B premiums, deductibles, and coinsurance premiums or out of pocket expenses. The savings plans are:

Specified Low-Income Medicare Beneficiary (SLMB) - Certain individuals who have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) and who are slightly above the national poverty level may qualify for State help in paying their Medicare Part B premium. To qualify, a person's annual gross income must not exceed 135% of the Federal Poverty Level and their financial resources such as bank accounts, stocks, and bonds must be within established limits. The Medicare Part B premium must be included in determining annual gross income.

Qualified Medicare Beneficiary (QMB) - The Qualified Medicare Beneficiary (QMB) in NJ is a component of the Medicaid/New Jersey FamilyCare program. QMB also helps pay for the Medicare Part B premium, deductibles and coinsurance. The QMB program has slightly lower income guidelines but the same asset guidelines as the SLMB program.

Qualifying Individual (QI-1) - Persons with income between 120% and 135% of the Federal Poverty Level may be eligible for assistance as a Qualifying Individual (QI) to have monthly Medicare Part B premiums paid.

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Medicaid/NJ FamilyCare

Medicaid/NJ FamilyCare is a joint federal‑state medical assistance program that pays medical bills for certain individuals of any age with low income and limited resources.  In NJ, persons eligible for Supplemental Security Income (SSI) are also eligible for Medicaid/NJ FamilyCare, and automatically receive it.

Persons 65+, or blind or disabled planning to live in a non‑institutional type setting should contact Social Security (1‑800‑772‑1213) to determine if they are eligible for Supplemental Security Income (SSI), since those eligible for SSI also receive Medicaid/NJ FamilyCare.  Persons seeking Medicaid/NJ FamilyCare assistance for institutional care should contact the Board of Medicaid/NJ FamilyCare.

Please call your County Board of Social Services for information on Medicaid/NJ FamilyCare.

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Group Health Insurance

Continuing Coverage After Leaving Employment (COBRA) - Employees covered by an employer‑provided group health insurance policy covering more than 20 persons, leaving the employ of their employer for any reason except gross misconduct, are entitled to a minimum of 18 months continuation of their group health insurance policy at group rates for themselves and their families provided that they are not covered by another group health insurance policy, and provided that the employer's policy remains in effect.

COBRA coverage for eligible individuals premiums have been temporary reduced by the American Recovery and Reinvestment Act of 2009 (ARRA).  Eligible individuals pay 35% of their COBRA premiums for up to 9 months.  If you elect this premium reduction, you are disqualified for the Health Coverage Tax Credit (see below), which could be more valuable to you than the premium reduction.  If you are eligible for other group health coverage (such as through a new employer’s plan or a spouse's plan) or Medicare you are not eligible for the premium reduction.

For information governing such continuance, contact the Employee Benefits Security Administration, Division of Technical Assistance and Inquiries, US Department of Labor, 200 Constitution Avenue, N.W., Room N-5658, Washington, DC 20210, telephone toll-free 1-866-487-2365 or 202-219-8776, or http://www.dol.gov/dol/topic/health-plans/cobra.htm.

Health Coverage Tax Credit

The federal Health Coverage Tax Credit was created to help certain displaced workers, certain retirees and employers experiencing financial hardship afford health insurance coverage.  The program begins operations August 1, 2009.  The credit is not available to everyone.  A worker receiving certain specified health coverage, such as Medicare, will be ineligible to use the HCTC program.  These HCTC extended benefits are only valid for the remainder of 2009 and 2010.

For more information about this program and about what is considered qualified health insurance, you may call the HCTC Program Customer Contact Center's toll-free telephone number of 1-866-628-4282 (for TTY/TDD users, call 1-866-626-4282).

You can find more information about the HCTC program by visiting the IRS Web site at www.irs.gov/individuals and selecting Health Coverage Tax Credit (HCTC).

Federally Qualified Health Centers - Medicare (FQHCs)

Medicare benefits have been expanded to include payment for certain preventive health-care services provided in federally qualified health centers (FQHCs). In addition, FQHCs may waive the deductible normally required under Medicare Part B and may limit the out-of-pocket costs by applying the co-pay responsibility of the Medicare beneficiary to a sliding scale based upon the beneficiary's ability to pay.

The FQHCs do not charge for any service for which Medicare beneficiaries are entitled to have payment made by the Medicare program. In order to be covered under Medicare Part B (Medical Insurance) the FQHCs must meet the U. S. Public Health Service criteria and agree to meet Medicare requirements.

In New Jersey, FQHCs are located in Atlantic, Bergen, Burlington, Camden, Cape May, Cumberland, Essex, Gloucester, Hudson, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Sussex, Union, and Warren Counties.

Information on these centers is available from the New Jersey Primary Care Association (NJPCA), toll-free at 800-328-3838 or 609-689-9930 or http://www.njpca.org.

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Last Modified: Friday, 03-Sep-10 15:36:16