Medicare and Medicaid - FAQs:

To report suspected Medicare fraud, call toll free 1-800-HHS-TIPS (1-800-447-8477).

HHS has joined with the Department of Justice and AARP to launch a national initiative against fraud, waste, and abuse in the Medicare program. The campaign,"Who Pays? You Pay," is aimed at both waste and at criminal fraud and abuse against the Medicare program.

Learn More:

• Medicare Fraud Overview (Medicare.gov)
   

Medicare is a Federal health insurance program for people 65 years or older, certain people with disabilities, and people with end-stage renal disease (ESRD). Medicare has two parts -- Part A , which is hospital insurance, and Part B, which is medical insurance. For information on Medicare, visit the Web site at https://www.medicare.gov or call toll free, 1-800-MEDICARE (1-800-633-4227).

Medicare Prescription Drug Coverage: Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information about this program, visit: http://www.medicare.gov/part-d/index.html.

Medicaid is a jointly-funded, Federal-State health insurance program that helps many people who can't afford medical care pay for some or all of their medical bills. Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy and stay healthy. Medicaid is available only to people with limited income. You must meet certain requirements to be eligible for Medicaid. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.

Learn More: http://www.medicaid.gov/

The State Children's Health Insurance Program (SCHIP), created in 1997, expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. Through the national "Insure Kids Now" initiative, each state has its own SCHIP program that makes health insurance coverage available to children in working families. For more information, visit www.insurekidsnow.gov or call toll free 1-877-KIDS-NOW (1.877.543.7669). This Web site andtoll free number also provide information on Medicaid.

Medicare

Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government.

Medicaid

Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines. To learn more about your state Medicaid program and other options available to you, use the insurance and coverage finder.

Learn More:

For more information regarding Medicare and its components, please go to www.medicare.gov.

For more information on Medicaid, please go to http://www.medicaid.gov

Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:

• You are receiving retirement benefits from Social Security or the Railroad Retirement Board.

• You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.

• You or your spouse had Medicare-covered government employment.

To find out if you are eligible, go the Medicare.gov eligibility tool.

If you (or your spouse) did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:

• You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (Note: If you have Lou Gehrig's disease, your Medicare benefits begin the first month you get disability benefits.)

• You are a kidney dialysis or kidney transplant patient.

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.

Prescription Drug Coverage

Since January 1, 2006, everyone with Medicare, regardless of income, health status, or prescription drug usage has had access to prescription drug coverage. For more information, you may wish to visit the Prescription Drug Coverage site at: http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-d.aspx.

How to get a replacement:

You can now request a replacement red, white, and blue Medicare card online on Social Security's (SSA) web site. Your card will be mailed within 30 days to the address SSA has on record.

This service can be accessed during the following hours:

Monday-Friday: 5 a.m. until 1 a.m.
Saturday : 5 a.m. until 11 p.m.
Sunday : 8 a.m. until 10 p.m.
Holidays : 5 a.m. until 11 p.m.

To make an online request, you will need the following information:

1. Your last (exact) payment amount or the month and year you last received a payment if you have received benefits in the last 12 months.
2. Your name as it appears on your most recent Social Security card
3. Your Social Security Number
4. Your Date of Birth
5. Your phone number in case we need to contact you about your request
6. Your e-mail address (optional)

You may also need:

1. Your Place of Birth
2. Your Mother's Maiden Name (to help identify you)

This service can be accessed via the Social Security Administration Web site. If you prefer, or if you are unable to use the online request to obtain a replacement Medicare card, call Social Security's toll-free number, 1-800-772-1213. Their representatives there will be glad to help you. You can also visit a local social security office. For the office closest to you try their Field Office Locator.

Changing your contact information:

To report your new address and request a replacement card at the same time, please call or visit Social Security.

To Contact Social Security in the United States:

• Call our toll-free number 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778. Representatives are available Monday through Friday between 7 a.m. and 7 p.m.
• Call or visit your local Social Security office. You can get directions and a map to your local Social Security Office by visiting the Local Office Locator.

Outside the United States, call or visit:

• Your nearest Social Security office,
• The closest U.S. Embassy or consulate, or
• The Veterans Affairs Regional Office (VARO) in the Philippines.

To learn whether a test, item, or service is coverded by Medicare.gov to Medicare.gov to find the answer.

Also, you can:

Apply for Medicare

Find health and drug plans

Get help with paying costs

Find out how Medicare works with other insurance

Find and compare doctors, nursing homes, home health agency, dialysis facilities, and hospitals that accept Medicare in your area.

You may report a change of name or address for the Medicare program by calling the Social Security Administration at 1-800-772-1213 or by visiting your local field office. Addresses and directions to the Social Security field offices may be obtained from the Social Security Office Locator.

You can get more information on changing your name on Social Security's web site. If you get benefits from the RailroadRetirement Board, call your local RRB office, or call 1-800-808-0772.

Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy and stay healthy.

Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. In general, you should apply for Medicaid if you have limited income and resources. You must match one of the descriptions below:

Pregnant Women

Apply for Medicaid if you think you are pregnant. You may be eligible if you are married or single. If you are on Medicaid when your child is born, both you and your child will be covered.

Children and Teenagers

Apply for Medicaid if you are the parent or guardian of a child who is 18 years old or younger and your family's income is limited, or if your child is sick enough to need nursing home care, but could stay home with good quality care at home. If you are a teenager living on your own, the state may allow you to apply for Medicaid on your own behalf or any adult may apply for you. Many states also cover children up to age 21.

Person who is Aged, Blind, and/or Disabled

Apply if you are aged (65 years old or older), blind, or disabled and have limited income and resources. Apply if you are terminally ill and want to get hospice services. Apply if you are aged, blind, or disabled; live in a nursing home; and have limited income and resources. Apply if you are aged, blind, or disabled and need nursing home care, but can stay at home with special community care services. Apply if you are eligible for Medicare and have limited income and resources.

Other Situations

Apply if you are leaving welfare and need health coverage. Apply if you are a family with children under age 18 and have limited income and resources. (You do not need to be receiving a welfare check.) Apply if you have very high medical bills, which you cannot pay (and you are pregnant, under age 18 or over age 65, blind, or disabled).

Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. To contact your Medicaid office, look up your State or Territory in the Contacts Database.

A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

Learn More with this Medicare.gov information:

• Medicare Advantage (Part C)
• Your Guide to Medicare Private Fee-for-Service Plans (PDF - 28 pages)
• Your Guide to Medicare's Preferred Provider Organization (PPO) Plans (PDF - 32 pages)
• Your Guide to Medicare Special Needs Plans (PDF- 20 pages)
• Use Medicare's Information on Quality to Help You Compare Plans (PDF - 5 pages

The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their web site at www.socialsecurity.gov.

The Medicare.gov Web site also has a tool to help you determine if you are eligibile for Medicare and when you can enroll.  It is called the Medicare Eligibility Tool.

IF YOU ALREADY RECEIVE BENEFITS FROM SOCIAL SECURITY:

If you already get benefits from Social Security or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month you turn age 65. You will not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If your 65th birthday is February 20, 2010, your Medicare effective date would be February 1, 2010. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2010, your Medicare effective date would be January 1, 2010.)

IF YOU ARE NOT GETTING SOCIAL SECURITY BENEFITS:

If you are not getting Social Security benefits, you can apply for retirement benefits online. If you would like to file for Medicare only, you can apply by calling 1-800-772-1213.

IF YOU ARE UNDER AGE 65 AND DISABLED:

If you are under age 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you will be automatically entitled to Medicare Part A and Part B beginning the 25th month of disability benefit entitlement. You will not need to do anything to enroll in Medicare. Your Medicare card will be mailed to you about 3 months before your Medicare entitlement date. (Note: If you are under age 65 and have Lou Gehrig's disease (ALS), you get your Medicare benefits the first month you get disability benefits from Social Security or the Railroad Retirement Board.) For more information about enrollment, call the Social Security Administration at 1-800-772-1213 or visit the Social Security web site. See also Social Security's FAQ: When should I sign up for Medicare benefits? which explains the enrollment process.

For more information, see Medicare.gov

Medicare Part B helps cover medically-necessary services like doctors’ services and tests, outpatient care, home health services, durable medical equipment, and other medical services. Part B also covers some preventive services. Look at your Medicare card to find out if you have Part B.

The basic medically-necessary services covered include:

• Abdominal Aortic Aneurysm Screening
• Ambulance Services
• Blood
• Bone Mass Measurement (Bone Density)
• Cardiac Rehabilitation
• Cardiovascular Screenings
• Chiropractic Services (limited)
• Clinical Laboratory Services
• Clinical Research Studies
• Colorectal Cancer Screenings
• Defibrillator (Implantable Automatic)
• Diabetes Screenings
• Diabetes Self-Management Training
• Diabetes Supplies
• Doctor Services
• Durable Medical Equipment (like walkers)
• EKG Screening
• Emergency Department Services
• Eyeglasses (limited)
• Federally-Qualified Health Center Services
• Flu shots
• Foot Exams and Treatment (Diabetes-related)
• Glaucoma Tests
• Hearing and Balance Exams
• Hepatitis B Shots
• HIV Screening
• Home Health Services
• Kidney Dialysis Services and Supplies
• Kidney Disease Education Services
• Mammograms (screening)
• Medical Nutrition Therapy Services
• Mental Health Care (outpatient)
• Non-doctor Services
• Occupational Therapy
• Outpatient Medical and Surgical Services and Supplies
• Pap Tests and Pelvic Exams (includes clinical breast exam)
• Physical Exams
• Physical Therapy
• Pneumococcal Shot
• Prescription Drugs (limited)
• Prostate Cancer Screenings
• Prosthetic/Orthotic Items
• Pulmonary Rehabilitation
• Rural Health Clinic Services
• Second Surgical Opinions
• Smoking Cessation (counseling to stop smoking)
• Speech-Language Pathology Services
• Surgical Dressing Services
• Telehealth
• Tests (other than lab tests)
• Transplants and Immunosuppressive Drugs

In your 2011 Medicare & You booklet, see pages 30–44 for a detailed description of common Part B-covered services listed above. Medicare may cover some services and tests more often than the timeframes listed in the charts if needed to diagnose a condition.

To find out if Medicare covers a service not on this list, visit www.medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Individuals under Age 21

EPSDT is Medicaid's comprehensive child health program. The program's focus is on prevention, early diagnosis,  and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state's Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.

If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state's Medicaid plan.

Individuals Age 21 and older

States may elect to provide dental services to their adult Medicaid-eligible population or, elect not to provide dental services at all, as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

Also, see:

• Medicaid and Dental Care

You will find guidance regarding the Prescription Drugs Medicare Part D program at:

http://www.cms.gov/PrescriptionDrugCovContra/12_PartDManuals.asp

Medicare does offer preventive benefits available under the health care law. These include a yearly wellness visit, tobacco cessation counseling, and a range of no-cost screenings for cancer, diabetes, and other chronic diseases.