MEDICARE & OTHER HEALTH CARE ASSISTANCE PROGRAMS

The Original Medicare Program and the Medicare+Choice Program
Medicare Coverage
        Hospital Care
        Skilled Nursing Facility Care
        Home Health Care
        Hospice Care
        Medicare Part B
Medicare Appeals
Other Health Care Assistance Programs
For more information

This article provides a summary of your Medicare benefits and of other health care assistance programs available in Connecticut. You can receive additional information free of charge from the Legal Assistance to Medicare Patients (LAMP) unit of Connecticut Legal Services, Inc.

Legal Assistance to Medicare Patients
1-800-413-7796 or (860) 456-1761

The Original Medicare Program and the Medicare+Choice Program

Anyone eligible for Medicare can now choose to receive Medicare benefits under the Original Medicare Program or through a Medicare+Choice health plan. A person enrolled in Medicare is called a Medicare beneficiary.

The Original Medicare Program has two parts:

Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.
Part B covers a wide range of most frequently used health services, such as doctor visits and diagnostic testing.

The Medicare+Choice Program offers Medicare beneficiaries different types of health plans through which they can receive their Medicare benefits. These health plans include:

Managed Care plans (Health Maintenance Organizations, Provider Sponsored Organizations, Preferred Provider Organizations),
Private Fee For Service plans, and
Medical Savings Accounts.

Currently, the Health Maintenance Organization (HMO) is the most common Medicare+Choice plan available. Medicare+Choice plans must provide at least the same benefits that the Original Medicare Program provides. Beneficiaries enrolling in a Medicare+Choice plan must also have Medicare Part B coverage.

Unless otherwise indicated, the information in this article you are reading applies to everyone entitled to Medicare benefits, whether Medicare benefits are received under the Original Medicare Program or through a Medicare+Choice health plan.

For more information on the Original Medicare Program and the Medicare health plans available under the Medicare+Choice Program, see your Medicare Handbooks, "Medicare and You 2000" and "Learning About Medicare Health Plans" published by the Health Care Financing Administration (the federal Medicare agency). For a free copy, call 1-800-MEDICARE. Information is also available on the Internet at www.medicare.gov.

Medicare Coverage

Hospital Care

Medicare will pay for inpatient hospital care when your illness or injury requires care that can only be provided in a hospital. If your condition improves and you only need skilled nursing home care, Medicare will cover your hospital stay until a bed is available in a Medicare certified nursing home.

Medicare will cover:

up to 90 days of hospital care for each "spell of illness"

A spell of illness ends, and a new spell of illness begins when you have not received hospital care or skilled care in a hospital or skilled nursing facility for more than 60 days. Each new spell of illness triggers another 90 days of Medicare coverage.

an additional 60 days of coverage per lifetime (known as lifetime reserve days) to be used as needed

up to 190 days of psychiatric hospital care per lifetime

You cannot be personally charged for Medicare covered hospital services unless you have been given a written notice stating that Medicare coverage is being denied or terminated. This notice must also advise you of your appeal rights.

Original Medicare:

If you are enrolled in the Original Medicare Program, you are responsible for paying:

the hospital deductible amount for each spell of illness, and
a portion of the cost of your care (known as a coinsurance) after the 60th day of hospitalization.

For 2000, the following amounts apply:
Deductible: $776 per spell of illness
Coinsurance:
        1st through 60th day: $0
        61st through 90th day: $194 per day
        Lifetime reserve days: $388 per day
These amounts increase every year.

Medicare+Choice:

If you are enrolled in a Medicare+Choice Managed Care plan, you are not responsible for paying the Medicare hospital deductible or coinsurance. However, some Medicare+Choice Managed Care plans do charge a plan hospital deductible and coinsurance.

In addition, some Medicare+Choice Managed Care plans may:

charge a monthly premium
charge a deductible and copayment (an amount you must pay whenever a service is provided) for other services provided under the plan
restrict you to specific hospitals and doctors.

Read the plan information carefully.

For more information, see our brochure Your Rights to Medicare Benefits for Hospital Care.

Skilled Nursing Facility Care

Medicare will only pay for a total of 100 days of skilled nursing facility (nursing home) care per "spell of illness." (See definition of spell of illness above). To qualify for this coverage, the following criteria must be met:

You must have been hospitalized for at least 3 days before being transferred to a skilled nursing facility;
You must be admitted to the skilled nursing facility within 30 days of discharge from the hospital (unless admission would not be medically appropriate until a later date);
You must receive services for a condition that was treated in the hospital immediately before admission to the facility
You must require and receive:
o     skilled nursing services 7 days per week; or
o     skilled rehabilitation therapy at least 5 days per week; or
o     a combination of both that totals 7 days per week;
The services must be provided under a doctor's order;
The skilled nursing facility must be Medicare approved.

Medicare coverage of your stay in the nursing facility will end before the 100 benefit days are exhausted if it is determined you no longer need skilled nursing or rehabilitation services.

You cannot be personally charged for Medicare covered skilled nursing facility services unless you have been given a written notice stating that Medicare coverage is being denied or terminated. This notice must also advise you of your appeal rights.

Original Medicare:

If you are enrolled in the Original Medicare Program,

Medicare will pay the full cost of the first 20 days in the nursing home.
You are responsible for paying a portion of the cost of your care for days 21 through 100 (known as a coinsurance).

For 2000, the skilled nursing facility coinsurance is $97 per day.
This amount increases every year.

Medicare+Choice:

If you are enrolled in a Medicare+Choice Managed Care plan, you are not responsible for paying the Medicare nursing facility coinsurance. However, some Medicare+Choice Managed Care plans may:

charge a monthly premium
charge a deductible and copayment (an amount you must pay whenever a service is provided) for other services provided under the plan
restrict you to specific nursing facilities and doctors.

Read the plan information carefully.

For more information, see our brochure Your Rights to Medicare Benefits for Skilled Nursing Facility Care.

Home Health Care

Medicare will pay for home health care services when you are considered to be confined to the home and your doctor orders skilled nursing or rehabilitation services.

Medicare will cover:

up to 35 hours per week of nursing care and home health aide services (combined)
physical, speech & occupational therapy
medical social services
medical supplies
medical equipment

The full cost of home health care is covered by Medicare. There are no deductible or coinsurance charges for home health care services regardless of whether you are enrolled in the Original Medicare Program or a Medicare+Choice Managed Care plan.

For more information, see our brochure Your Rights to Medicare Benefits for Home Health Care.

Hospice Care

Original Medicare:

Hospice care is available for terminally ill patients and covers a wide range of medical and counseling services. Those who elect hospice care choose comfort care over curative care for the terminal illness. A doctor must certify that the patient is terminally ill, and the patient must elect hospice care in writing.

Medicare+Choice:

Medicare+Choice plans are not required to provide hospice benefits to Medicare enrollees. However, the plan must inform each enrollee eligible to elect hospice care about the availability of hospice care. An enrollee electing hospice benefits continues to be enrolled in the Medicare+Choice plan and is entitled to receive any benefits other than those that are the responsibility of the Medicare hospice.

Medicare Part B

Medicare Part B will pay for a wide variety of medical services including: doctor services, home health services, laboratory services, durable medical equipment, ambulance travel, outpatient services and medical supplies.

Original Medicare:

Medicare beneficiaries enrolled in the Original Medicare Program, are responsible for paying:

the Part B monthly premium ($45.50 in 2000)
the Part B annual deductible ($100), and
20% of the amount that Medicare approves for payment (known as a coinsurance).

Medicare +Choice:

Medicare beneficaries who wish to enroll in a Medicare+Choice Managed Care plan must enroll in Medicare Part B and are responsible for paying:

the Part B monthly premium ($45.50 in 2000)
any copayment required by the plan. (A copayment is a specific amount which is due at the time a medical service is provided. Copayments are usually between $5 and $15 for each service).

Read the plan information carefully.

For more information, see our brochure Your Right to Medicare Part B Benefits.

Medicare Appeals

The Medicare appeal system was created by the federal government to allow you to challenge what you believe is an incorrect coverage decision. Medicare law is very complicated and coverage errors are frequently made. Denials of Medicare coverage can often be successfully challenged through a Medicare appeal.

The attorneys at LAMP may be able to represent you through the appeal process. LAMP is a unit of Connecticut Legal Services, Inc, a not-for-profit law firm that provides free advice, information, and in some cases, representation regarding Medicare coverage. Representation by LAMP is always free of charge. An appeal won't affect future Medicare or Social Security payments and requires little patient or family involvement. You have little to lose and often much to gain by filing an appeal.

Call LAMP to find out how a denial of coverage can be challenged.
1-800-413-7796 or (860) 456-1761

Other Health Care Assistance Programs

The Connecticut Medicare Assignment Program (ConnMAP) is run by the Connecticut Department of Social Services (DSS). ConnMAP prevents doctors and other Part B providers from charging Medicare beneficiaries enrolled in the Original Medicare Program more than the rates set by Medicare. ConnMAP enrollees are only responsible for the Part B deductible and the 20% coinsurance amount. ConnMAP is available to single persons with annual incomes of $23,925 or less and couples with annual incomes of $28,875 or less. For more information or an application, call 1-800-443-9946.

The Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) is run by the Connecticut Department of Social Services (DSS). ConnPACE helps those who are 65 or over or disabled pay for prescription drugs, insulin and insulin syringes. ConnPACE is available to single persons with annual incomes of $14,700 or less and couples with incomes of $17,700 or less. There is a $25 annual registration fee and a $12 copayment for each prescription. For more information or an application, call 1-800-423-5026.

The Qualified Medicare Beneficiary (QMB) Program, The Specified Low Income Medicare Beneficiary (SLMB) Program, and The Additional Low Income Medicare Beneficiary (ALMB) Program are offered by the Connecticut Department of Social Services (DSS). These programs are available to all Medicare beneficiaries with limited income and assets. The asset limits for all three programs are $4,000 for a single person and $6,000 for a couple. The income limits vary for each program.

The QMB Program pays your Medicare premiums, deductibles, coinsurance, and copayment amounts. The QMB Program is available for single persons with incomes of $879 per month or less and for couples with incomes of $1,304 per month or less. QMB benefits can duplicate most of the coverage provided by Medicare Supplemental Insurance (Medigap) policies. If you enroll in the QMB Program, you could consider canceling your Medigap insurance.

The SLMB Program will pay the Medicare Part B premium. The SLMB Program is available for single persons with incomes of $1018 per month or less and couples with incomes of $1,491 per month or less.

The ALMB Program will pay all or a portion of the Medicare Part B premium, based on the applicant's income. ALMB is available for single persons with incomes of $1,123 to $1,401 per month and for couples with incomes of $1,632 to $2,007 per month. Benefits are available on an annual first-come, first-served basis.

Note: The income limits listed above for the QMB, SLMB and ALMB programs are effective April 1, 2000 to March 30, 2001. For more information or an application, call DSS at 1-800-609-5627.

For more information, see our brochure The Qualified Medicare Beneficiary Program, The SLMB and the ALMB Program.

For more information or assistance:

Medicare Services (serving all of CT)

Legal Assistance to Medicare Patients
Connecticut Legal Services, Inc.
872 Main Street, P.O. Box 258
Willimantic, CT 06226
(860) 456-1761 or 1-800-413-7796
www.ctelderlaw.org

Elder Law Services

Eastern Connecticut
Connecticut Legal Services, Inc.
872 Main Street, P.O. Box 258
Willimantic, CT 06226
(860) 456-1761 or 1-800-413-7796

Western Connecticut
Connecticut Legal Services, Inc.
85 Central Avenue
Waterbury, CT 06722
(203) 756-8074 or 1-800-413-7797

Southwestern Connecticut
Connecticut Legal Services, Inc.
211 State Street
Bridgeport, CT 06604
(203) 336-3851

North Central Connecticut
Greater Hartford Legal Assistance
80 Jefferson Street
Hartford, CT 06106
(860) 541-5000

South Central Connecticut
New Haven Legal Services
426 State Street
New Haven, CT 06510
(203) 946-4811

This document was produced by Elder Law and Legal Assistance to Medicare Patients/CT Legal Services and Legal Assistance Resource Center of CT.

The information in this document is based on the law as of January 2000. We hope that the information is helpful. It is not intended as legal advice for an individual situation. If you need further help and have not done so already, please call Statewide Legal Services (see above) or contact an attorney.