Medicare is a health insurance program for persons age 65 and older, people who have received Social Security
Disability benefits for 24 consecutive months, or individuals of any age with permanent kidney damage. It is
administered by the Health Care Financing Administration and enrollment is handled by the federal Social Security
Administration. Medicare is available regardless of income or the asset levels of the individual or family.
Persons approaching age 65 may apply for Medicare 3 months prior to their 65th birthday. You may apply for
Medicare even if you do not plan to receive Social Security Benefits. If you are already receiving Social
Security or Railroad Retirement benefits when you turn 65, you are enrolled in Medicare automatically, and will
receive your Medicare card in the mail.
Medicare consists of two parts -Part A and Part B.
Part A is hospitalization insurance, and covers hospital, home health, skilled nursing and hospice care. It also covers 80% of the approved cost for some durable medical equipment.
Part A is automatic with the receipt of Social Security, and is premium free for most beneficiaries. For those who do not qualify for premium free Part A benefits, coverage may be purchased if certain requirements are met. If the beneficiary has less than 29 quarters of Social Security coverage, the cost of the premium is $315 a month. If the beneficiary has 30-39 quarters of coverage, the cost is $175.
Part B Medicare is voluntary and covers the service of doctors, out-patient care, durable medical equipment, routine mammograms for the elderly, and some other services. You are automatically enrolled in Part B when you become entitled to premium Part A benefits, unless you don't want it. Part B is generally a good deal because the federal government subsidizes about 75% of the program costs. If elected, the premiums are usually deducted from your Social Security checks.
The initial enrollment period for Part B and premium Part A runs for seven months beginning three months before the month in which you turn 65. If you do not enroll during this period, you will have to wait until the next general enrollment period. General enrollment periods run from January 1 through March 31.
If you do not enroll during your initial seven month enrollment period, your premiums will go up. The Part B premium goes up ten percent every year after you were first eligible. So, it is usually best to sign up when you first become eligible.
The increase in Part A is limited to ten percent no matter how late you enroll.
These higher premiums do not apply if you are 65 or over and are covered by group health
insurance by your current employer.
Both parts of Medicare are relatively inexpensive methods of covering the costs of many health care services. Medicare, however, does not cover all medical expenses. It is important to check what amount of payment will be made for a particular service. Most Medicare claims are reduced. Sometimes payment for a particular good or service is even denied.
Allowable costs are determined by Medicare regulations, but can be appealed if you believe an exclusion is improper.
Contact your local Medicare carrier for more information about appeals and Medicare coverage. The South Dakota carrier can be reached by calling 1-800-437-4762.
As you approach age 65 carefully review any current health insurance policies you are covered under. Some policies will reduce their coverage once you are eligible for Medicare. For example, the insurance company might become a Medicare Supplement policy, rather than pay for the entire cost of the service. If this is the case with your current plan, you need to apply for Medicare.
DRGs (Diagnosis Related Groups)
Diagnosis Related Groups (DRGs) have changed the nature of Medicare Part A coverage. With the adoption of DRGs, hospitals are now paid a fixed amount for inpatient care. This fixed rate is based on the type of illness or injury being treated. This change is designed to avoid excessive stays in the hospital. It also gives the hospital financial incentive to discharge patients as early as possible.
The average length of stay for Medicare beneficiaries has decreased since DRGs were adopted. However, you are entitled to receive care in a hospital for as long as it is medically necessary. No one can discharge you without your doctor's approval.
If you are hospitalized and someone tells you your Medicare coverage or "days" will lapse or end, contact the hospital administrator or Social Security representative. An appeals process is available.
Each hospital has a Utilization Review Committee. The URC makes the initial determinations about Medicare coverage. If your physician does not agree with the URC's decision, your hospital must appeal to the State Peer Review Organization (PRO). The PRO will then make the determination on your coverage. PROs are groups of health care professionals paid by the federal government to monitor the quality of care provided to
Medicare patients. PROs also take complaints from Medicare recipients in that state.
For more information on complaints and appeals, contact the South Dakota Foundation for Medical Care at 1-800-658-2285. The foundation serves as the state's PRO.
For additional assistance and questions regarding Medicare enrollment or for The Medicare
Handbook contact your local Social Security Administrator.
South Dakota has offices located in Sioux Falls, Rapid City, Huron, Aberdeen, Yankton,
Watertown, Pierre, and Pine Ridge. The toll free number for the Social Security Administration is 1-800-722-1213.
More detailed questions should be directed to your Medicare carrier, the Peer Review Organization, or the Health Care Financing Administration at 1-303-844-4024.
The South Dakota Senior Health Information Education Program (SHINE) might be able to assist you with about Medicare. They can be reached by calling 1-800-822-8804.