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Medicare

Medicare is a national program that is the same throughout the United States.  Medicare beneficiaries are usually enrolled in parts A, B, and D of the Medicare Program.

Medicare Part A - The Hospital Insurance Program
Medicare Part A covers substantial hospital care but covers very limited:

  • Nursing Home Care
  • Home Health Care
  • Hospice Care

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Medicare Part B – The Medical Insurance Program
Medicare Part B services are primarily provided on an outpatient basis and not in the hospital.  Part B services must be medically necessary and reasonable.  Services that are not considered medically necessary and reasonable, or that are considered preventive or routine are generally not covered. 

Medicare Part B coverage includes:  

a.   doctors’ services;
b.   therapists’ services:  physical, occupational, speech pathology;
c.   clinical social worker;
d.   clinical psychologist;
e.   outpatient hospital services;
f.    rural health clinic services;
g.   outpatient rehabilitation facility services;
h.   limited ambulance services;
i.    X-ray treatment;
j.    radiation treatment;
k.   prosthesis;
l.    braces;
m.  medical equipment;
n.   supplies;
o.   home health services;
p.   mammography screening annually for women 40 and older;
q.   one pair of conventional eyeglasses after a cataract surgery;
r.    injectable drugs for bone fracture related to postmenopausal osteoporosis;
s.   flu, pneumococcal and hepatitis B vaccines;
t.    pap smear screenings and pelvic exams;
u.   anti-cancer drugs administered orally;
v.   colorectal, prostate cancer and glaucoma screenings;
w.  bone mass measurement;
x.   diabetes self-management educational and training services and medical nutrition therapy;
y.   blood glucose monitoring and testing strips for all diabetics.

Specific Exclusions are:

  • dental care
  • eye examinations
  • eyeglasses, except for glasses needed after a cataract operation
  • hearing tests and hearing aids
  • routine physical examinations
  • general foot care, except that Medicare will pay for therapeutic shoes and shoe inserts for patients who have severe diabetic foot disease
  • most care received outside of the United States (Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa or considered the United States)

 

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Medicare Part D – The Prescription Drug Program
Medicare’s Prescription Drug Program began on January 1, 2006.  Part D covers outpatient prescriptions through many private insurance companies, each with its own set of drugs it will or will not cover.  When choosing or changing a specific drug plan, the beneficiary should look at the plan’s list of covered drugs, also called “formulary” to make sure that the prescriptions needed by the patient are all covered by the plan. You can read more about the various drug plans in New York State by checking www.medicare.gov.  You may also want to contact the Health Insurance Information, Counseling, and Assistance Program (HIICAP) for assistance on Medicare and other insurance programs at 1-800-701-0501 or by checking its website www.aging.ny.gov/HealthBenefits/HIICAPIndex.cfm.

NOTE:  New York State has its own prescription drug plan for New York State residents 65 and older whose annual income is less than $35,000 for an individual and $50,000 for a couple.  This plan is called Elderly Pharmaceutical Coverage Insurance or EPIC.

 

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Home Health Care Services
Before a patient can obtain home health care, he or she must meet five qualifying conditions:

  • The patient must be “homebound” as defined by Medicare.
  • The services are provided under a physician’s plan of care and reviewed every two months.
  • The services are provided by a certified home health agency or a long term home health care program.
  • The services are “Reasonable and Necessary” for treatment of a patient’s illness or injury.
  • The patient needs “intermittent skilled” nursing services or physical therapy, speech therapy or has a continued need for occupational therapy.
NOTE: Non-medical or custodial care is not covered unless the patient also needs skilled care.

When Is a Patient Considered “Homebound” For Medicare’s Purposes?
In order to be considered homebound the patient should generally be confined to the home but the patient does not have to be bedridden.  A patient may leave the home and still be considered “homebound” as long as

1) Absences are to obtain medical treatment, including attending adult day services; and

2) Non-medical absences are infrequent or for a short duration.  Non medical absences that will not affect the patient’s homebound status include attending a religious service, family reunion, graduation, and funeral, taking a walk, drive, or trip to get a haircut for instance.

What Kind Of Home Health Services Does Medicare Cover?
Once a beneficiary has met the qualifying conditions listed above, Medicare will cover the following services:

  • Part-time or intermittent skilled nursing care and home health aide services;
  • Physical, speech and occupational therapy;
  • Medical social services; and
  • Medical supplies and equipment.
NOTE:  Medicare generally does not cover non-skilled care, such as the care provided by a home attendant or housekeeper.

What Is Meant By "Intermittent Skilled Nursing Care"?
Intermittent skilled nursing care is care that is needed less than seven days each week and can be provided safely on a very limited (intermittent) basis.  This means that a person who has Alzheimer’s disease and who is otherwise healthy but needs someone to watch him or her constantly, make lunch, give showers, and help in general with the activities of daily living will not be eligible for Medicare-covered home health care.

MEDICARE PART A INTERMEDIARIES
INSURANCE COMPANY TYPE OF CLAIMS PROCESSED AREA SERVED

Empire Medicare Services
P.O. Box 4846
Syracuse, NY 13221
800-442-8430
www.empiremedicare.com

Most hospital inpatient and outpatient services and all skilled nursing facility (SNF) claims

Most of New York State

United Government Services
P.O. Box 2019
Milwaukee, WI 53201
800-531-9695
www.ugsmedicare.com

Home health and hospice claims

Entire New York State

 

MEDICARE PART B CARRIERS
INSURANCE COMPANY TYPE OF CLAIMS PROCESSED AREA SERVED

Empire Medicare Services
P.O. Box 2280
Peekskill, NY 10566
800-442-8430
www.empiremedicare.com

Medical services, including doctors and diagnostic tests outside of hospital

New York City (except Queens), counties of Columbia, Delaware, Dutchess, Greene, Nassau, Orange, Putnam, Rockland, Suffolk, Sullivan, Ulster, and Westchester

Group Health, Inc. (GHI)
P.O. Box 1608
Ansonia Station
New York, NY 10023
800-632-5572
www.ghi.com

Medical services

Queens

Upstate Medicare Division
33 Lewis Road
P.O. Box 5200
Binghamton, NY 13902
800-252-6550
www.umd.nycpic.com

Medical Services

Rest of New York State not serviced by Empire and GHI

Health Now NY, Inc.
DMERC Division
P.O. Box 6800
Wilkes-Barre, PA 18773
800-842-2052
www.umd.nycpic.com

Durable medical equipment (i.e. wheelchair, hospital bed) and related services

Entire New York State

Copyright © 2004 Brookdale Center on Aging of Hunter College/Samuel Sadin Institute on Law
All rights reserved.  Permission to reproduce must be obtained in writing.

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