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What is Medicare?
Medicare is the
national program that serves as the primary source of health insurance for
older people and many people with permanent disabilities. The program
was enacted in 1965 as Title 18 of the Social Security Act. Medicare has
evolved significantly over the years; in 2003 additional major changes were
made. Pursuant to the 2003 law, Medicare now includes a prescription drug
discount card program and, in 2006, beneficiaries will be offered a limited
prescription drug benefit.
What Health Care Services Does Medicare Cover?
Medicare works like
other health insurance. It pays a portion of the cost of certain necessary
medical services. To be covered the Medicare Act says the services must be
"reasonable and necessary for the treatment, diagnosis, or rehabilitation of
an illness, injury, or malformed body member." Often cost sharing is
required of the individual Medicare beneficiary, including premiums,
deductibles and co-payments.
program is divided into parts. Part A covers inpatient hospital care,
skilled nursing facility (nursing home), home health, and hospice care. Part
B, which is optional, and for which one pays a monthly premium, covers
medical care provided by doctors and other health care providers, long-term
home health care, durable medical equipment, outpatient hospital services,
physical, speech, and occupational therapy. Part C of Medicare, (also known
as Medicare Advantage), provides payment mechanism options including
managed care plans. Medicare Part D is the new prescription drug program,
which will be effective January 1, 2006.
Who is eligible?
retirement recipients who are over 65 years old and individuals who have
received Social Security disability benefits for 24 months are eligible for
Medicare. In addition, individuals who receive Railroad Retirement Benefits
and individuals who have End Stage Renal Disease (ESRD) or Amyotrophic
Lateral Sclerosis (ALS or "Lou Gerhig’s Disease") are also eligible for
Medicare is not a
welfare program and should not be confused with Medicaid. While Medicaid is
a state run health care financing program for low-income people, Medicare is
a federal program and an individual’s income and assets are not
considerations in determining eligibility.
As for others,
people with Multiple Sclerosis can qualify for Medicare
coverage before age 65 if Social Security determines that they are
permanently disabled and they have received Social Security disability
benefits for 24 months. People with MS will also be eligible for Medicare
when they reach age 65 if they receive Social Security or Railroad
Retirement benefits. Individuals who retire early, and decide to
receive Social Security retirement benefits at age 62, must still wait until
they are 65 to receive Medicare.
How Do People Enroll?
individuals who are 65 and are entitled to Social Security or Railroad
Retirement benefits are automatically enrolled in Medicare Part A and will
be deemed to have also enrolled in Part B. Individuals must enroll in
Part A during an "initial enrollment period," which begins in the third
month before the person reaches age 65 (or reaches age 65 and becomes a U.S.
citizen, or a permanent resident who has lived continually in the U.S. for
the five years immediately preceding application for Medicare). The initial
enrollment period extends for the next seven months.
An application for
Social Security or Railroad Retirement will also suffice for Medicare. A
separate application is not necessary. Individuals who choose to take early
Social Security retirement benefits will be automatically enrolled in
Medicare when they attain age 65.
Those who are 65
but who delay receipt of Social Security benefits may still enroll in
Medicare but must file an application. Individuals who qualify for Medicare
because they have received Social Security or Railroad Retirement disability
benefits for 24 months are entitled to Medicare but also must file an
Medicare may be made with Social Security after receiving disability
benefits for 24 months. Effective July 1, 2001 the
24-month waiting period was eliminated for disabled persons diagnosed with
can be extended up to 78 months after disability benefits are terminated if
the beneficiary is engaged in an approved nine-month trial work period after
a period of disability. The previous period of disability benefits will
count toward the 24-month eligibility requirement should the beneficiary
seek to reestablish Medicare eligibility.
miss the initial enrollment period must wait for a "general enrollment
period’ to enter Medicare Part B. The general enrollment period is the first
three months of each calendar year (January 1 through March 31). Medicare
Part B benefits do not begin until July of that year.
When the new Part D
prescription drug benefit goes into effect in 2006, individuals will have to
affirmatively enroll in a prescription drug plan if they want the benefit.
The initial enrollment period will occur from November 15, 2005 through May
15, 2006. Every year after that individuals will only be able to
enroll in a Part D drug plan or change the plan in which they have enrolled
from November 15 through December 31 of each year.
Penalties apply for
late enrollment under Part A, Part B, and Part D. Under Part A, a 10%
penalty, based on the monthly Part A premium price, is imposed for every
month of late enrollment up to twice the number of months for which the
beneficiary has failed to enroll. Under Part B, a 10% penalty is also
imposed. The penalty is for each full year (12 month gap) of late
enrollment. Unlike Part A, there is no end-point to the penalty under Part
B. Under Part D, the penalty will be the greater of an amount that is
actuarially sound for each uncovered month or 1% of the national average
monthly beneficiary base premium for each uncovered month, whichever is
greater. As with Part B, there is no end-point to the penalty.
How Are Medicare Benefits Provided?
Medicare benefits were provided to all beneficiaries in the same way
throughout the country, in a manner similar to traditional private health
insurance. Beginning in the mid-1990s, however, managed care plans became
part of the Medicare program; creating different delivery systems in
different parts of the country. With the advent of Medicare Part C in 1997,
more kinds of benefit plans became available. The plans are known as
Medicare Advantage (MA, formerly known as Medicare+Choice). The options
include "coordinated care plans," (the term used in the law for managed care
plans) as well as preferred provider organizations, medical savings
accounts, private fee-for-service plans, and other options. In most parts of
the country the only available Medicare Advantage options are managed care
plans. The majority of beneficiaries are part of the traditional Medicare
program; a significant number, however, receive their Medicare through
Medicare Advantage plans.
receive Medicare through a managed care plan by filing an enrollment form.
Once the choice is made, the beneficiary generally must receive all of his
or her care through the plan in order to receive Medicare coverage.
Beneficiaries can change their minds, disenroll from their managed care
plan, and return to "original" Medicare. An
election to enroll or disenroll from a Medicare Advantage plan becomes
effective the month following the month in which the election is made,
regardless of the date of the election.
managed care benefit is different from the traditional Medicare
"fee-for-service" system but coverage should theoretically be the same or
better. Often a Medicare managed care plan administers the health care
treatment of an enrollee by the use of a physician (known as a "gatekeeper")
who must approve the patient’s referral to specialized care. (Some
Medicare managed care plans permit beneficiaries to go directly to a
specialized care provider, without the gatekeeper’s approval, in return for
payment of an extra premium.)
Does Medicare Cover Prescription Drugs?
Medicare has not covered prescription drugs; that is changing. There
are now a number of ways in which Medicare beneficiaries in general, and
people with MS in particular, can receive some assistance with the cost of
some of their medications from Medicare.
Medicare Part B for
Certain Intramuscular Injections
Medicare will cover intramuscular injections provided in a
physician’s office for medications such as the MS drug Avonex. Coverage is
generally available only for intramuscular, not intravenous injections, and
only when Medicare presumes that people in general, not the particular
patient, cannot self-inject the drug. This presumption has been made for
Avonex. To be covered, the drug and administration must be provided in
the physician’s office and the services are subject to the Part B annual
deductible and 20% co-payment. A few Medigap insurance policies will
cover the co-payment.
Medicare Part B
Drug Replacement Demonstration Project
A Medicare "demonstration project" provides a potential option for
assistance for a limited number of people. The Medicare law passed in
December 2003 authorized a demonstration project for 50,000 people for
certain drugs specifically related to certain identified diseases, including
MS. (The other diseases include some cancers, rheumatoid arthritis,
osteoporosis, and hepatitis C.) $500,000 was appropriated for this project
of which approximately 40% will be devoted to anti-cancer drugs.
Participants for the project will be chosen by lottery. Applications
will be accepted through September 30, 2004; the first lottery will be on
September 1, 2004. Application forms are available on the Medicare agency
Medicare Part D
In January 2006 Medicare began
a new Part D which will offer some assistance with the cost of prescription
drugs. The Part D program will be administered by private entities. Coverage
will be available for those beneficiaries who choose to enroll, meet the
deductible, and pay a monthly premium. Medicare will then pay for part of
the cost of those drugs that are on the chosen plan’s drug formulary. After
Medicare has paid a set amount of dollars, the beneficiary will be required
to meet a second, larger deductible, which has become known as the "donut
hole". At that point additional coverage with a lower beneficiary
co-payment responsibility will begin. Beneficiaries with low-incomes
will be eligible for assistance with the cost sharing responsibilities.
People eligible for both Medicare and Medicaid will begin receiving drug
coverage under Medicare rather than Medicaid.
Pharmaceutical Assistance Programs
Approximately 30 states have their own state legislated and administered
programs that provide assistance with the cost of prescription drugs,
usually for individuals who meet certain income guidelines. To learn more
about a particular state’s benefit contact the state agency that administers
their Medicaid program.
Can People with MS and Other
Long-Term Illnesses Receive Medicare Coverage?
There is a long-standing myth that people with long-term illnesses and those
in need of long-term care are not covered by Medicare. This is not true.
Unfortunately, beneficiaries are too often denied Medicare coverage for a
variety of services on the grounds that they have a chronic or stable
condition, that their condition will not improve, and/or that the services
are to maintain, not to improve, their condition.
Medicare coverage determinations should be based on what is medically
necessary and on the specific qualifying criteria for the particular health
care setting and services. The Medicare Act excludes certain services from
coverage, and other coverable services may not meet the qualifying criteria
in a given case. However, people should not be denied benefits for otherwise
coverable services simply because they have a long-term illness such as MS.
Further, beneficiaries are legally entitled to an individualized assessment
of their qualification for coverage. These assessments should be made based
on valid standards for the particular services at issue, not on generalized
assumptions about people with similar diagnoses. This is important for
people with MS who are too often erroneously denied Medicare coverage for
physical therapy, home health care, and other important and necessary
Medicare Coverage Available for Long-Term Services and Long-Term Care?
Medicare may cover some services for long periods of time. People with MS
and other chronic conditions may be eligible for physical, occupational, and
speech therapy as long as the services are skilled and medically necessary.
This is so even if the services are needed to maintain the individual’s
condition rather than to restore prior function.
In addition, while
Medicare covers only a limited amount of nursing home care in only limited
circumstances, the Medicare home health benefit, and sometimes the hospice
benefit, can be a source of long-term care and coverage for beneficiaries.
Indeed, in 1980, Congress made an affirmative decision to extend the
Medicare home health benefit for individuals who have not necessarily
experienced an acute illness and who need home care for long periods of
time. The 1980 statutory changes removed the requirement that the
beneficiary have a prior hospital or skilled nursing facility stay in order
to obtain home health coverage, and eliminated a 100 visit limitation on
Physical, Occupational, and Speech Therapies
People with MS are often denied necessary physical therapy services on
the grounds that they are not going to improve. Importantly,
restoration is not the deciding factor in determining the right to
coverage. The question for determining the right to coverage
should be are the skills of a therapist necessary to establish, provide,
and/or supervise the services. Skilled therapy can be needed to maintain
the individual’s condition or to arrest further deterioration; in such
cases Medicare coverage may be warranted. Each person is entitled to an
individualized assessment of his/her right to Medicare coverage.
For many years there was a cap on the annual Medicare payment for
physical, occupational, and speech therapy; this dollar limit was lifted
by Congress in 2003. It will be reviewed again for services
beginning in 2006.
Home Health Care
Unlike the Medicare skilled nursing facility benefit, which provides
coverage for a short period of time, Medicare coverage can be available
for long-term home health care if the qualifying criteria are met.
There is no legal limit on the duration of time for which home health
coverage is available. Further, Medicare covers home health
services in full, with no required deductible or co-payments from the
beneficiary. Services must be medically necessary and reasonable and the
following criteria must be met:
- A physician has signed or will sign a plan of care.
- The patient is or will be homebound. This criterion is met
if leaving home requires a considerable and taxing effort which may
be shown by the patient needing personal assistance, or the help of
a wheelchair or crutches, etc. Occasional but infrequent
"walks around the block" are allowable.
- The patient needs or will need physical or speech therapy, or
intermittent skilled nursing (from once a day for periods of 21 days
at a time if there is a predictable end to the need for daily
nursing care, to once every 60 days); and
- The home health care is provided by, or under arrangement with,
a Medicare-certified provider.
triggering conditions described above are met, the beneficiary is
entitled to Medicare coverage for home health services. Home health
- Part-time or intermittent nursing care provided by or under
the supervision of a registered professional nurse.
- Physical, occupational, or speech therapy;
- Medical social services under the direction of a physician;
- To the extent permitted in regulations, part-time or
intermittent services of a home health aide.
Balanced Budget Act of 1997 made significant revisions to the
Medicare home health benefit (BBA). These changes were effective
for services provided on or after January 1, 1998. While
the BBA did not change the Medicare home health coverage
criteria, the changes did alter the payment structure and, in
practice, this change resulted in reduction in services,
particularly for individuals in need of long term or extensive
care. As with the SNF benefit, denials of Medicare home health
coverage should not be predicated upon particular diagnoses or
the fact that a patient’s condition is chronic or unlikely to
improve. Each patient should be provided with an
individualized assessment of his or her right to coverage in
light of the qualifying criteria. Additional advocacy tips
include the following:
- Medicare coverage should not be denied simply
because the patient’s condition is "chronic" or stable."
"Restorative potential" is not necessary.
- Resist arbitrary caps on coverage imposed by the intermediary.
For example, do not accept provider or intermediary assertions that
aide services in excess of one visit per day are not covered, or
that daily nursing visits can never be covered.
- There is no legal limit to the duration of the Medicare home
health benefit. Medicare coverage is available for necessary
home care even if it is to extend over a long period of time.
- The doctor is the patient’s most important ally. If it
appears that Medicare coverage will be denied, ask the doctor to
help demonstrate that the standards above are met. Home care
services should not be ended or reduced unless the doctor has
- In order to be able to appeal a Medicare denial, the home health
agency must have filed a Medicare claim for the patient's care.
You should request, in writing, that the home health agency file a
Medicare claim even if the agency told you that Medicare will deny
Medicare provides a limited benefit for nursing home coverage for a
limited period of time. Nursing homes are referred to in Medicare
as skilled nursing facilities (SNFs). The benefit is available for
a short time at best - for up to 100 days during each spell of illness.
If Medicare coverage requirements are met, the patient is entitled to
full coverage of the first 20 days of SNF care. From the 21st
through the 100th day, Medicare pays for all covered services except for
a daily coinsurance amount ($109.50 per day in 2004) The SNF patient
will not be entitled to any Medicare coverage unless he or she was
hospitalized for at least three days prior to the SNF admission and,
generally, was admitted to the SNF within 30 days of the hospital
There are certain requirements that must be met in order for a patient
to receive Medicare coverage. These requirements include:
physician must certify that the patient needs skilled nursing
beneficiary must generally be admitted to the SNF within 30 days
of a 3-day qualifying hospital stay.
beneficiary must require daily skilled nursing or
care needed by the patient must, as a practical matter, only be
available in a skilled nursing facility on an inpatient basis.
The skilled nursing facility must be a
If coverage is
available, the benefit for SNF care is intended to cover all the
services generally available in a SNF:
Nursing care provided by registered
Bed and board,
Other services necessary to the health of the patient.
services recognized as skilled by Medicare include the following:
management and evaluation of care plan.
Observation and assessment of the
patient's changing condition;
and gastrostomy feedings;
assessment of rehabilitation needs and potential;
Therapeutic exercises or activities;
evaluation and training.
Medicare coverage is often denied to individuals who qualify under the law.
In particular, beneficiaries are often denied coverage
because they have certain chronic conditions such as MS, Alzheimer’s
disease, Parkinson’s disease, or because they need nursing or therapy to
maintain their condition. These are not legitimate reasons for
Medicare denials of SNF care. The question to ask is does the patient
need skilled nursing and/or therapy on a daily basis, not, does the patient
have a particular disease or will s/he recover. Other important advocacy
tips include the following:
restoration potential of a patient is not the deciding factor in
determining whether skilled services are needed.
is the patient's most important ally. If it appears that
Medicare coverage will be denied, ask the doctor to help demonstrate
that the standards described above are met.
management of a plan involving only a variety of "custodial"
personal care services is skilled when, in
light of the patient's condition, the aggregate of those services
requires the involvement of skilled personnel.
requirement that a patient receive "daily" skilled services will be
met if skilled rehabilitation services are
provided five days per week.
nursing home issues a notice saying Medicare coverage is not
available and the patient seems to satisfy the criteria above, ask
the nursing home to submit a claim for a formal Medicare coverage
determination. The nursing home must submit a claim if the
patient or representative requests; the patient is not required to
pay until he/she receives a formal determination from Medicare.
Medicare has provided coverage for hospice care. Hospice care is
intended to provide palliative and supportive care for the terminally ill
and their families rather than treatment for the underlying condition.
With the passage of the BBA in 1997, Medicare now covers two 90-day periods
of hospice care and an unlimited number of additional periods of 60 days
each. Formerly, Medicare coverage was available for two 90-day periods, for
one 30-day period, and for a fourth unlimited period of hospice care.
In order to receive
Medicare hospice coverage, a patient must elect to opt into hospice coverage
and, as a consequence, out of most other Medicare coverage for treatment of
the underlying terminal condition. The hospice care must generally be
provided by, or under arrangement with, one Medicare-certified hospice
program during each period.
To receive Medicare
coverage for hospice care, the patient must be certified as terminally ill
by the patient's physician and/or the hospice staff physician, and the
hospice care must be part of a written plan of treatment established by the
attending physician and hospice medical professionals. If coverage
conditions are met, Medicare is available for an array of services,
Counseling services for the patient and the family or other
supplies, equipment appliances, and
biologicals (including pain medication);
Physical, occupational, and speech therapy.
What Can Be Done to Contest a
Because of the size and complexity of the Medicare program and because of the
desire to contain costs, Medicare coverage is often denied when it should be
granted. Sometimes these denials are a result of errors; sometimes they are a
result of policy that places cost containment concerns over the needs of
individual beneficiaries. Whatever the underlying reasons for the denial, the
Medicare program includes an appeals system that is designed, at least in
theory, to reverse erroneous denials and to correct mistakes. If the patient's
attending physician feels the care in question is medically necessary and the
care is not simply excluded from Medicare coverage (e.g., hearing aids, dental
care, skilled nursing facility care when there was not a prior hospital stay),
the beneficiary should appeal.
ARTICLES AND UPDATES