MEDICARE   Medicare is a federal health insurance program established by Congress in 1965. It provides health care benefits for people 65 or older, people younger than 65 who have certain disabilities, and people of any age who have permanent kidney failure. While medicare gives basic protection against health care costs, it won't cover all your medical expenses or the costs of most long-term care. The Centers for Medicare and Medicaid Services (CMS) is the organization that manages Medicare. However, Social Security offices actually enroll applicants into the program and will give you specific information about it.   Medicare benefits are divided into three parts:   1. Part A primarily covers inpatient hospital, skilled nursing facility care and home health care. Once enrolled in Medicare, you will receive these benefits automatically and do not pay premiums for them (you've already paid for them through your taxes).  Hospital Inpatient Care:  For each benefit period, Medicare pays all covered costs except the Part A deductible during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days. A "benefit period" begins when you are admitted to a hospital and ends when you have been out of the hospital or have not received skilled care in a nursing facility for 60 consecutive days. In addition to this "benefit period," you are given 60 "lifetime reserve" days that can be used only once. Skilled Care in a Skilled Nursing Facility(Nursing Home): Medicare provides 100 percent of expenses for the first 20 days of skilled nursing care after three consecutive days of hospitalization - not including the day of discharge. This nursing care must be physician-prescribed to be covered by Medicare. For days 21-100 in a skilled nursing facility, the beneficiary must pay  a co-payment( this is where it comes in handy to have Medicare Part B or a supplemental insurance so it can pay the co-payment). Beginning with day 101, you are responsible for the costs yourself. Medicare does not pay for custodial care if it makes up the bulk of services received in a nursing facility. (Custodial care is care given by someone who is not medically skilled. Help with dressing, walking, or eating are examples). Because many people in nursing facilities receive this type of care, it may be useful for you to keep in mind that Medicare does not pay for it. Home Health Care: Medicare completely covers an unlimited number of home health visits, provided that a physician has determined you are home-bound and that the services follow a physician's prescribed plan of care, requires skilled nursing services on an intermittent basis, or skilled physical, occupational or speech therapy services, and the services are provided by a licensed home health agency. Hospice Care:  If a doctor certifies - and a hospice medical director agrees -  that the patient is terminally ill (is expected to have less than six months to live), and the patient chooses the hospice benefit over the standard Medicare benefits (must sign a statement waiving Medicare coverage), Medicare will pay for two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period of care, your doctor must submit the appropriate authorization. Hospice care keeps the patient as comfortable as possible - it doesn't provide cure-oriented treatment.  2. Part B covers physician services, rehabilitation therapy services, 0utpatient hospital services, ambulance services, and a number of other medical supplies and services. You can turn down Part B if you choose because it requires a monthly premium or you can purchase an affordable supplemental insurance provided by many health insurance companies such as AARP, Humana, Preferred Care Partners, Blue Cross Blue Shield, Cigna, etc. Make sure that you get only supplemental coverage. Some of those companies will talk you into accepting them as primary care insurance, which is all right if you are younger and don't need too many medical services, but not if you are older and have multiple health problems( diabetes-insulin dependent being one of them). You will not need Medicare Part B or a supplemental insurance if you are in certain states that have Medicaid Waiver/Diversion Programs, and if you are accepted into the program, you will have basic Medicare and Medicaid.   3. Part D will not be discussed here because of it's complexity and you should consult a Medicare Specialist if you are interested in the services.   You are eligible for Medicare if you: Are age 65 or older; Are United States citizens or legal aliens who have resided in the United States continuously for at least five years; Are age 65 or older and eligible for Social Security or Railroad Retirement benefits; Are age 65 or older and the spouse or former spouse of someone who receives Social Security or Railroad Retirement Benefits; Worked long enough in a federal, state, or local government job to meet the Social Security disability program requirements (this is if they are under 65). Those 65 or older (or a spouse) must have 40 or more quarters of Medicare covered employment; Have been receiving Social Security disability benefits for at least two years (24 months); Have End Stage Renal (Kidney) Disease.    When to apply for Medicare:   Medicare applications are handled through your local Social Security office and are usually submitted when you apply for Social Security. To ensure that your entrance into Medicare is problem-free, you should contact your local Social Security office within three months before you turn 65. If you fail to enroll within this three-month period, you'll have to pay a penalty for late enrollment. This time frame is important particularly for those who have retired or plan to retire before age 65.   Medicare benefits choices:   You have two choices in how to receive Medicare benefits. You can either use the basic (traditional) Medicare (fee-for-service) delivery system, in which you visit a hospital or doctor of your choice and pay a fee for services rendered, or you can join a Health Maintenance Organization (HMO) with a Medicare contract. An HMO is a network of health care providers (like general practitioners, specialists, and other medical experts) that offers comprehensive health care coverage.   Medicare does not cover for: Custodial care -- This is given by a medically unskilled person to help a patient with the tasks of daily living, such as  walking, bathing, or dressing. Even if you are in a hospital that participates in Medicare or are in a skilled nursing facility, Medicare will not cover the cost of the service if it is mainly custodial. Dental care and dentures . Routine checkups and tests directly related to those checkups (except for some screening, Pap smears, and mammograms which are covered). Most immunization shots (except for flu and pneumonia shots which Part B helps pay). Most prescription drugs (except for individuals who have elected for Part D) Routine foot care (with certain exceptions). Services outside the United States (with certain exceptions). Tests for, and the cost of, eyeglasses or hearing aids . Personal comfort items, like a phone or TV in your hospital room. Cosmetic Surgery Experimental Procedures

MEDICARE  HMO   Many HMOs have contracts with the Health Care Financing Administration to serve Medicare beneficiaries. An HMO health plan provides coverage to doctors on the plans referral list. With most plans, the patient chooses a primary care doctor, and all health care is managed by this doctor. Most plans require a referral from the primary care doctor before a patient can see a specialist. If a patient decides to see a doctor not on his plan's list, there is no insurance coverage.   Requirements for enrollment in HMO: You must be enrolled in Medicare Part B; You cannot have elected care from a Medicare-certified hospice; You cannot be medically determined to have end stage renal disease (ESRD). However, if you are already a member of an HMO when you become eligible for Medicare, and that HMO has a contract with Medicare, you can remain in your HMO even if you have ESRD; and You must live within the service providing area for which the HMO has a Medicare contract.   Advantages of an HMO: HMOs with Medicare contracts provide all hospital and medical benefits covered by Medicare. Many of these HMOs provide benefits beyond those Medicare pays for. These may include preventive care, prescription drugs, dental care, hearing aids, and eyeglasses. HMO users do not have to pay the co-payments and deductibles of Medicare, nor do they need Medigap or other supplemental insurance. HMO copayment amounts are generally lower than what Medicare asks for, if they exist at all. HMOs do not usually have deductibles. Unlimited lengths of hospital stay are generally covered entirely by an HMO: in other words, you can return to an HMO for hospital services many times over for long periods of time without fear that benefits will end. The coordination of services at an HMO could enhance the quality of your health care. There is very little paperwork involved when using a HMO, and it can be easier to get all your health services from one health care source.   Disadvantages of an HMO:   Most HMOs will limit your access to specialists and services within their networks. If you have medical needs requiring specialized services, or if you don't want to take the chance of having your access limited to specialists in the future, you may want to consider joining an HMO carefully.   It is important to keep in mind that most HMOs -- the "risk" HMOs -- are paid a flat fee by Medicare to provide you health services regardless of the actual costs of your health care. HMOs, in effect, take a "risk" on your health. One of the arguments for "risk" HMOs is that they strive to maintain your health because it is in their best interests. Theoretically, this means an HMO will be motivated to prevent your illnesses and treat them early. The negative side of the "risk" argument is that HMOs is that they seek to manage costs. To a certain extent they have to, because they are not being paid a fee for each individual service rendered. This may mean doctors will have higher-than-normal caseloads of patients or will be encouraged to maintain referral limits. The possibility that the negative aspects of "risk" HMOs may affect the quality of your medical care is an important consideration. If you are a diabetic on insulin unable to self inject the insulin due to a permanent medical condition and you have no caregiver or family member that can give you the insulin, you will not be able to receive the unlimited services from a home health agency under HMO. You will have to disenroll from HMO becoming automatically basic Medicare Fee-For-Service, and a nurse under home health services will be able to come and administer your insulin daily. HMO will also limit you on the amount of physical therapy services that you will need in a rehabilitation center or in your own home. A patient under HMO receives much less rehabilitation time than a patient under basic Medicare(fee-for-service).   If you plan to travel frequently, you may not want to join a "risk" HMO: these HMOs require you to use services in only particular facilities.   Disenroll from Medicare HMO:   To disenroll from an HMO, you should write a letter saying you want to leave your health plan. This letter can be sent to either the HMO office or the Social Security Administration (or the Railroad Retirement Board) or you can ask for a fax number and fax your letter to them. Ask for a confirmation in writing( via e-mail, fax or mail) that the disenrollement took place. You will be out of the plan the first of the following month.  Make sure you have a supplemental insurance coverage or you can ask the HMO if they will want to continue covering you as a secondary(supplemental) insurance.