Learning Objectives 1. Describe various federal health programs that help older Americans obtain health care and medical services, such as Medicare, Medicaid, Supplemental Security Income (SSI), QMB and SLMB, HMOs and Medigap insurance. 2. Explain following terms: deductibles, co-insurance, Medicare intermediaries and carriers, and prescription coverage.

Several federal programs exist to help older Americans obtain health care and medical services. In this article, we describe each briefly and suggest ways to obtain more information about each program.

Medicare

Medicare is the federal health insurance program for people 65 or older and certain disabled people. It is administered by the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services. Social Security Administration offices across the country take applications for Medicare and provide general information about the program. Most Americans over the age of 65 are covered by Medicare, since the only requirement to participate is that you are eligible for some type of Social Security benefit. The majority of people who are receiving Social Security automatically get their Medicare card and handbook in the mail when they turn 65.

Medicare is divided into two parts: Part A Hospital Insurance helps pay for inpatient care in a skilled nursing facility, home health care, and hospice care. Part B Medical Insurance helps pay for doctors' services, outpatient hospital services and supplies.

Part A requires participants to pay deductibles (the amount of money you pay before Medicare starts paying), but does not charge premiums (a monthly charge to participate in the program). Part B has both deductibles and co-insurance (the percent of the bill you must pay, usually 90%) and also requires premiums. Deductibles, coinsurance, and premium costs are set each year based on formulas established by law. Any person who qualifies for Part A may enroll in Part B. Also, most U.S. residents age 65 or older can enroll in Part B.

If you do not qualify for Medicare Part A, you may purchase it if you wish. Purchasing Medicare Part A costs $261 per month. If these premiums are also beyond your means, you may qualify for coverage under the Medicaid program in your state.

Deductibles and Co-Insurance

During 1993, Part A beneficiaries were responsible for an inpatient hospital deductible of $676 for the first 60 days of hospitalization. This deductible is the amount the beneficiary must pay before Medicare begins paying for services and supplies. Part B beneficiaries must pay an annual deductible of the first $100 in approved charges for covered medical expenses before Part B coverage begins. In addition, after the Part B beneficiary pays the annual deductible, she will owe a co-insurance share of the Medicare-approved amount for most services and supplies. This co-insurance share is 20% of the Medicare-approved amount. Thus, Medicare will pay 80% of the health care bill and the beneficiary will pay 20% to participating physicians, that is, physicians who have agreed in advance to accept assignment on all Medicare claims. Nonparticipating physicians can bill the Medicare patient an additional 15% above what Medicare allows, making the patient responsible for 35% rather than 20% of the bill.

Medicare Intermediaries and Carriers

The Health Care Financing Administration uses insurance companies called "intermediaries" and "carriers" to administer the Medicare program. Intermediaries process inpatient and outpatient insurance claims submitted on your behalf by hospitals, skilled nursing facilities, home health agencies, hospices, and certain other providers of services. Insurance carriers handle claims for services by doctors and suppliers covered under Medicare's Part B claims.

Although Medicare is a federal program, participants are often surprised that coverage can vary from one geographic area to another. Coverage for some procedures, such as PAP smears and mammograms, is guaranteed by existing federal guidelines, so these procedures are covered in all states. However, Medicare coverage for other procedures or services may vary from region to region, depending on the Medicare insurance carrier. An example of how this affects the person with osteoporosis is the coverage for bone density testing. Currently, Medicare covers Single Photon Absorptiometry (SPA), Radiographic Absorptiometry (RA), and bone biopsies. Dual Photon Absorptiometry (DPA) is not covered, and Dual Energy X-ray Absorptiometry (DXA) and Quantitative Computed Tomography (QCT) coverage varies from region to region.

To find out who your Medicare carrier is, simply check the listing in the back of your Medicare handbook. The Medicare handbook is revised each year and it is only mailed to eligible individuals when there have been major changes in the Medicare program. To obtain a new handbook, contact your local Social Security office.

Prescription Coverage

Medicare only pays for prescription medications used while the participant is hospitalized. Coverage does not include the cost of medications that the patient requires at home. There are few exceptions to this policy. For the osteoporosis patient, the one important exception is calcitonin injections. Medicare will cover calcitonin injections for women participants who are housebound, cannot self-administer the medication, and require a home health nurse to come to the home to give the injection. The home health visit is 100% covered and the cost of calcitonin is 80% covered.

Medicaid

Medicaid is a joint federal and state program that pays to provide health care services and nursing home care to mothers and children and older people who meet eligibility criteria set each year by federal and state law. In most states, Medicaid is linked to eligibility for Aid to Families with Dependent Children or Supplemental Security Income programs. This means an adult without dependent children must meet eligibility guidelines and be over 65 or blind or disabled for at least two years to receive Medicaid benefits.

Supplemental Security Income (SSI)

Low income individuals who are over 65, or blind, or disabled may qualify for SSI. SSI is also administered by the Social Security Administration. SSI was established to supplement a recipient's very low financial resources, so there are strict guidelines about who qualifies. While individuals may own their own home, individuals must have less than $2000 in resources and couples less than $3000 in resources to qualify. Generally, someone over 65 with unearned income (pensions, Social Security, or interest income) of less than $458 a month qualifies for federal SSI payments. A couple qualifies with unearned income of less than $687. The Social Security Administration allows $20 of unearned income each month, which raises the unearned income levels to $478 for individuals and $707 for couples. The Social Security also allows $65 a month of earned income.

Qualified Medicare Beneficiary (QMB) and Special

Low Income Medicare Beneficiary (SLMB)

Older individuals with very low incomes and very limited resources may have difficulty paying for medications and doctor's visits. These individuals may benefit from the Qualified Medicare Beneficiary (QMB) or Special Low Income Medicare Beneficiary (SLMB) programs. The QMB and SLMB laws require state Medicaid programs to pay the Medicare premiums, deductibles, and co-insurance for older persons and persons with disabilities who are in need, even if they do not meet the income eligibility guidelines for Medicaid. The income criteria for these programs change each year. If you have Medicare but are unable to afford supplemental coverage, you may qualify for special benefits through one of these two programs.

Medigap Insurance

Since the cost of Medicare deductibles, co-insurance and uncovered services such as prescriptions can add up, beneficiaries may wish to consider buying a Medicare supplemental insurance (Medigap) policy that pays some or all of these expenses. There are federal laws that require companies providing Medigap insurance to clearly list the benefits offered so that beneficiaries can compare benefits and costs of different policies. If you decide to purchase a Medigap policy, carefully review what each policy covers and select the one that best meets your needs. Individuals who are eligible for QMB do not need Medigap insurance as the QMB benefits pay all Medicare-related out-of- pocket expenses. However, if your Medigap plan covers services that Medicare does not, such as prescription drugs, you may wish to keep that policy as well. If you qualify for SLMB, you may wish to keep supplemental insurance to pay for deductibles and coinsurance, since SLMB does not provide this service.

Health Maintenance Organizations (HMOs)

To reduce out-of-pocket expenses, Medicare beneficiaries in some areas may have the option of enrolling in a coordinated care plan such as a Health Maintenance Organization (HMO). Many beneficiaries find that this is a good way to get the most for their health care dollars, and many HMOs offer benefits not ordinarily covered by Medicare for little or no additional cost. These benefits may include preventive care, dental care, hearing aids, and eyeglasses, but the list of services varies from plan to plan.

For information on SSI and the application process: call (800) 772-1213 between the hours of 7:00 AM and 7:00 PM.

QMB information and to request an application: 1 -800-638-6833

Social Security: contact your local office or

1-800-772-1213

For more information on the Medicare program, order a free copy of Guide to Health Insurance for People with Medicare, from:

Consumer Information Center

Dept. 87

Pueblo, CO 81009

Source: National Osteoporosis Foundation

Reprinted with permission