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What should I know about Medicare?

Authored By: GeorgiaLegalAid.org

Medicare benefits in Georgia

What should I know? +

Contents


What is Medicare?

Medicare is health insurance for:

  • People 65-years-old or older,

  • People with certain disabilities,

  • People with permanent kidney failure requiring dialysis or a kidney transplant.

 

Medicare has different parts that cover different services. You might enroll in a plan that includes some or all parts.

 

Medicare Part A

Part A is hospital insurance. It covers: 

  • Inpatient care in hospitals,

  • Short-term stays in skilled nursing facilities,

  • Hospice care, and

  • Some home health care.

 

Medicare Part B

Part B is for outpatient care and doctor’s visits. When you apply for Medicare, you can sign up for Part A (Hospital Insurance) and Part B (Medical Insurance). You must pay a premium for Part B coverage, but you can decline the coverage. However, if you enroll in Part B later on, you may have to pay a late enrollment penalty, which could last as long as you have Part B coverage. Unless you qualify for a special enrollment period, if you enroll late the penalty will increase your monthly premium by 10 percent for each 12-month period you were eligible for Part B, but didn’t sign up for it, unless you qualify for a “special enrollment period”. It covers:

  • Doctor’s visits,

  • Outpatient care, including:

    • Physical therapists,

    • Occupational therapists,

    • Some home health care

    • Medical supplies

If you are unable to pay your premium, you might qualify for help through a Medicare Savings Program.

 

Medicare Part D

Part D is prescription drug coverage. Most people pay a monthly premium for Part D coverage. If you meet income and resource limits, you may qualify for a program called Extra Help or a state program to pay drug costs.

 

Medicare Plan Options

There are two main options for Medicare plans:

  1. Original Medicare. Original Medicare includes Part A and Part B.

    1. You can join a separate Part D plan.

    2. You can buy Supplemental Coverage (Medigap) to cover out-of-pocket expenses.

  2. Medicare Advantage. “All-in-one” plans that generally cover Part A, B, and D, plus extra benefits like vision, hearing, and dental.

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What are my rights with Medicare?

Everyone with Medicare has certain rights. This includes the right to:

  • Be protected from many forms of discrimination. No company or agency that works with Medicare can treat you differently because of your:

    • Race,

    • Color,

    • National origin,

    • Disability,

    • Age,

    • Religion, or

    • Sex

  • Have your personal and health information kept private.

  • Get information about Medicare. The information should be easy to understand and help you make health care decisions. Information includes:

    • What care is covered.

    • What Medicare pays.

    • How much you will have to pay.

    • What to do if you want to file a complaint or appeal.

  • Have access to doctors, specialists, and hospitals.

  • Learn about your treatment choices in clear language and participate in treatment decisions.

  • Get health care services in a language you understand and in a culturally-sensitive way.

  • Get Medicare-covered services in an emergency.

  • Get a decision about health care payment, coverage of services, or prescription drug coverage.

    • When a claim is filed, you get a notice letting you know what will and won’t be covered. The notice comes from one of these:

      • Medicare

      • Your Medicare Advantage Plan (Part C)

      • Your other Medicare health plan

      • Your Medicare Prescription Drug Plan (Part D)

    • If you disagree with the decision of your claim, you have the right to file an appeal.

  • Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.

    • If you disagree with a decision about your claims or services, you have the right to appeal.

  • View your personal health information.

  • File complaints, including complaints about the quality of your care.

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What are my responsibilities with Medicare?

  • You are responsible for signing up for or changing your Medicare plan at the correct time. 

  • You are responsible for making sure your doctors and medical providers take Medicare. 

  • You are responsible for paying any premiums and deductibles for your plan.

  • If you disagree with a plan’s decision not to cover a service or prescription, you are responsible for filing an appeal. 

  • If have an issue with the quality of care, you are responsible for filing a complaint.

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What can I do? +

Contents


Who is eligible for Medicare?

Who can get Part A? 

You are eligible for Part A at no cost if you are 65 or older AND:

  • You are getting or are eligible to get Social Security or the Railroad Retirement Board (RRB),

  • Your spouse (living or deceased, including divorced spouses) gets or is eligible for SS or RRB benefits,

  • You or your spouse worked long enough in a government job and paid Medicare taxes, or

  • You are the dependent parent of a fully insured deceased child.

 

You are eligible for Part A at no cost if you are under age 65 if:

  • You have been eligible for Social Security disability benefits for 2 years,

  • You get a disability pension from the RRB and meet certain conditions,

  • You get Social Security disability benefits because you have Lou Gehrig’s disease,

  • You worked in a government job and paid Medicare taxes and you have met the requirements of the Social Security disability program for 2 years,

  • You’re age 50 or over and:

    • are the child or widower of a worker who has worked long enough under SS or in a Medicare-covered government job AND

    • You meet the requirements of the Social Security disability program.

  • You have permanent kidney failure and you need maintenance dialysis or a kidney transplant AND:

    • You are eligible for or get monthly benefits under Social Security or the railroad retirement system,

    • You’ve worked long enough in a Medicare-covered government job, or

    • You’re the child or spouse of a worker who has worked long enough under SS or a Medicare-covered government job.

 

Even if you don’t qualify for free Medicare Part A, you may be able to get it by paying a monthly premium.

 

Who can get Parts B, D and Medicare Advantage?

Anyone who is eligible for Part A can sign up for Medicare Part B by paying a monthly premium. Even if you are not eligible for Part A, you can buy Part B if you are 65 years old or older and are either:

  • A U.S. citizen, or

  • A lawfully admitted noncitizen who has lived in the U.S. for five years.

 

If you have both Part A and Part B, then you are eligible for a Medicare Advantage plan. 

 

If you have either Part A or Part B (or both), you can buy Medicare Part D.

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How do I apply for Medicare?

If you are already receiving Social Security benefits, you will automatically be enrolled in Medicare Parts A and B the month you turn 65. You don’t need to do anything. 

 

If you are not yet receiving Social Security benefits, you can apply for Medicare benefits when you become eligible due to disability or illness or three months before your 65th birthday.

 

There are three ways to apply:

 

Check with the Social Security office to learn about your enrollment period. You may have to pay more if you don’t enroll when you first become eligible. 


How do I apply for a Medicare Savings Program to help with my Medicare costs?

If you cannot pay for your Medicare Part B costs, you might get help through a Medicare Savings Plan. You may qualify if:

  • You get Medicare,

  • You have a limited income, and 

  • Your resources are no more than $7,390 for one person or $11,090 for a couple. 

 

The various Medicare Savings Plans may pay for your:

  • Medicare premium,

  • Co-insurance, and

  • Deductible.

 

Georgia residents can apply for a Medicare Savings Plan by:

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How can I apply for Extra Help for my Medicare prescription drug plan costs?

If you cannot pay for Medicare Part D, you might get a low-income subsidy through Social Security’s Extra Help program. 

 

You may be eligible if your income and assets are below a certain level. You can find out if you are eligible and apply for Extra Help by:

  • Filling out an application online.

  • Calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) and: 

    • asking for an application be mailed to you or 

    • applying over the phone. 

  • Applying in person at your local Social Security office.

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How do I appeal a Medicare decision?

If you disagree with a Medicare decision you can appeal that decision. There are five levels to the appeals process. If you don’t agree with the decision at the first level, you can appeal to the next level. 

 

For free help filing a Medicare appeal, contact GeorgiaCares

 

The initial appeals process will differ depending on your Medicare plan.

 

Appeals process with Original Medicare

Every three months, you will get a Medicare Summary Notice (MSN). The MSN will list any services and supplies billed to Medicare and what Medicare paid.  

 

You must file your appeal within 120 days of getting your MSN.

 

To file the appeal:

  • Fill out a “Redetermination Request Form” and 

  • Send it to the company that handles claims for Medicare. You can find the address for the appeals company on your MSN.

 

You should get a decision within 60 days.

 

Appeals process with Medicare Advantage

For Medicare Advantage plans, you appeal through your plan. You can find instructions for an appeal in your plan materials. 

 

You must ask for an appeal within 60 days of the Medicare decision.

 

Your plan must give you a decision on most issues within 30 calendar days. However, if you think your health could be seriously harmed by waiting for a decision, you can ask for an expedited decision. An expedited decision must be made within 72 hours.

 

Appeals process with Medicare Prescription Drug Plan (Part D)

For Medicare drug plans, you appeal through your plan. 

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How do I file a complaint about my care?

If you are unhappy with the quality of care or service you get from Medicare, you can file a complaint.

 

Contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)  complaints about the quality of care you received, including:

  • Poor care from a doctor, hospital or provider,

  • An unnecessary treatment or surgery, 

  • Unsafe conditions at a hospital,

  • Not getting treatment you needed.

 

In Georgia, the BFCC-QIO is KePro.

Toll Free: (888) 317-0751 (TTY 1-855-843-4776)

Local: (813) 280-8256

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How can I get help with Medicare issues?

For free help with Medicare issues, contact the GeorgiaCares program online or at 1-866-552-4464. GeorgiaCares can help you:

  • Enroll in a Medicare plan

  • Review your Medicare Summary Notices

  • Understand your Explanation of Benefits

  • File an appeal or claim

  • Apply for financial assistance for Medicare expenses

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Information

Last Review and Update: Jan 21, 2020