Medicare 2009 Fact Sheet

Part A Medicare Benefits 

Inpatient Hospital Care

Includes a semiprivate room, meals, general nursing and other hospital services and supplies. This does not include private duty nursing, a television or telephone in your room, or a private room, unless medically necessary. Inpatient mental health care coverage in a psychiatric facility is limited to 190 days in a lifetime.

Benefits are paid on the basis of "benefit periods." A benefit period begins the first day you are hospitalized and ends when you have been out of a hospital or skilled nursing facility for 60 consecutive days. If you enter a hospital again after 60 days, a new benefit period begins.

In 2009, a Medicare beneficiary is responsible for a deductible of $1,068 for the first day of each benefit period, after which Medicare pays for up to 60 days of full hospital care. For days 61-90, the beneficiary is responsible for $267 per day (co-payment). In addition, a beneficiary has 60 lifetime reserve days, and would be responsible for a co-payment of $534 per day for days 91-150. There is no Medicare coverage for days 150-365.

Skilled Nursing Facility (SNF) Care

A semi-private room, meals, skilled nursing, rehabilitative services, and other services and supplies are provided after a hospital stay of at least 3 consecutive days if ordered by the doctor. Medicare covers 100 days of skilled nursing or rehabilitative care in a SNF, provided the SNF is approved by Medicare and your treatment is connected with the illness that caused you to be hospitalized. You must need skilled nursing care or skilled rehabilitative care on a daily basis. Medicare pays days 1-20 in full; the beneficiary is responsible for a $133.50 per day co-payment for days 21-100. No custodial or intermediate nursing home care is provided.

Hospice Care

Medicare pays for unlimited hospice care for terminally ill patients in a Medicare-approved hospice program, through four benefit periods. There are no deductibles or co-payments, except for covered prescription drugs and inpatient respite care. Individuals must choose hospice care. You pay a copayment of up to 5 dollars for outpatient prescription drugs and 5 percent of the Medicare-approved amount for inpatient respite care (short term care given by another caregiver so the usual caregiver can rest.)

Home Health Care

Part-time skilled nursing care, physical therapy, speech-language therapy, home health aide services, durable medical equipment, supplies, and other services.

Medicare provides for full payment of intermittent part-time skilled care from registered nurses, therapists, and home health aides from a Medicare-approved home health agency. Intermittent part-time care is generally defined as daily care for 5 days a week up to 2 or 3 weeks. In exceptional cases, longer care may be provided. In order to be eligible, a beneficiary must meet all the following criteria: (1) Be under the care of a doctor, (2) Need care for a specific illness, (3) Be homebound, (4) Need skilled services, and (5) Need services on a part-time or occasional basis. 

If you require skilled services (nursing, physical therapy, or speech therapy), you may also receive occupational therapy, social work services, and home health aide services if your physician determines you need them. Prior hospitalization is not necessary to receive home health services under Medicare. You pay nothing toward home health services and 20 percent of the Medicare-approved amount for durable medical equipment.

Part B Medicare Benefits: 

Physician Services (Inpatient and Outpatient), Outpatient Services, Outpatient Physical, Speech, and Occupational Therapy, and Durable Medical Equipment and Supplies

A Medicare beneficiary pays a $135 annual deductible and a 20 percent co-payment for Medicare-approved charges and services. Medicare pays 80 percent of its approved charge. A beneficiary pays all costs above Medicare-approved charges ("excess charge.") Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge Medicare beneficiaries for covered services. The limiting charge is 115 percent of the fee schedule amount for non-participating physicians. NOTE: Certain Medicare covered services, such as mental health services, physical and occupational therapy, and certain services rendered by special practitioners have special payment rules.

 Drugs and Biologicals

Medicare pays the full-approved charge for flu shots and pneumococcal vaccine and its administration. Neither the annual Part B deductible nor the 20 percent co-payment apply to these services. Medicare covers certain oral anti-cancer drugs, subject to the Part B premium and 20 percent co-payment rules. Medicare helps pay for Hepatitis B vaccine and its administration, furnished to beneficiaries considered to be at high or intermediate risk of contracting the disease. Medicare also pays for immuno-suppressive drugs post transplant, if the transplant was Medicare-approved.

Preventive Health Benefits

• A beneficiary 40 years of age and older is entitled to one screening mammogram every year. Medicare will pay a maximum of 80 percent of the approved charge; the Medicare Part B deductible will not apply. Beneficiaries must receive their mammography services at a Medicare-approved mammography site.  
• Medicare pays for one Pap smear screening and related medically necessary physician services, including a physician's interpretation of the results of the tests every two years, or more frequently for women at high risk of developing cervical or vaginal cancers. 
• Medicare will provide coverage for colon cancer screening tests; there are a variety of tests covered depending upon a person's risk of developing colon cancer. 
• Medicare covers the costs of blood glucose monitors and most of the cost of test strips for people with diabetes, (both insulin and non-insulin dependent), and will provide coverage for educational and training services furnished to an individual with diabetes by a qualified provider at the direction of the beneficiary's physician. 
• For an individual at high risk, Medicare provides coverage (80 percent) of bone mass measurement tests that detect bone loss and qualify to determine the likelihood of the person developing osteoporosis. 
• Medicare will cover prostate cancer screening, (digital rectal exams and prostate specific antigen tests) for men age 50 and older, 80 percent coverage for the exam, no co-insurance or deductible for the PSA test.
• Medicare will cover glaucoma screening, once every 12 months for an individual who is at risk for glaucoma, including people with diabetes or a family history of glaucoma. 
• Vaccinations include a flu shot once a year, a pneumonia vaccination once in your lifetime and a hepatitis shot for high risk individuals. 
• Medicare covers a one-time review of your health, as well as education and counseling about the preventive services you need. You must have the physical exam within the first six months you have Medicare Part B.
• Medicare covers diabetic screenings, up to one to two tests per year, depending on your risk level.
• Medicare covers blood test screenings for cholesterol, lipid and triglycerides levels once every five years.

Back to Top

Some Typical Services Not Covered by Medicare:

• Long term custodial care (nursing home)
• Private hospital room (unless determined to be medically necessary,) telephone and television
• Private duty nursing
• First 3 pints of blood, if you cannot replace them in some manner
• Routine physical exams, including most pre-surgical exams and tests
• Dental care and dentures
• Routine hearing exams and hearing aids
• Routine eye exams and eyeglasses, except cataract lenses (Routine eye exams for individuals with medical conditions which affect sight may be covered)
• Eye refractions
• All over-the-counter drugs
• Routine podiatry care (Routine care for persons with certain medical conditions, such as diabetes or vascular heart disease may be covered)
• Inpatient psychiatric care, after 190 days (lifetime limit)
• Acupuncture, and most chiropractic services
• Cosmetic surgery, unless caused by accidental injury or to improve the function of a malformed body part
• Full-time home care, homemaker services, home delivered meals
• Christian Science practitioners and Naturopath's services
• Orthopedic shoes, unless part of a leg brace and included in orthopedist's charges
• Ambulance service from home to doctor's office
• Services provided outside the United States (except for certain hospital and physician services in Canada or Mexico, under certain conditions)

Medicare Monthly Premiums:

Part A Premium  

Most individuals are entitled to "premium-free" Part A benefits based on their or their spouse's work history. Other individuals may be eligible to purchase Part A benefits at $443 per month, if they have less than 40 quarters of Social Security coverage.

Part B Premium

The regular Part B premium will be $96.40 per month in 2009, if a person has an income of under $85,001 or a couple has an income under 170,000. Individuals who fall above the income requirements for this premium will be subject to an income-related monthly adjustment amount. To find out more information, contact the Centers for Medicare and Medicaid at 1-800-MEDICARE.

Important Related Subjects:

Qualified Medicare Beneficiary Program (QMB)

Known as QMB or Quimby, this program will pay the premiums, deductibles, and coinsurance payments of the Medicare Program for older and disabled individuals who are financially eligible. The current QMB eligibility guidelines are:  $887/month income and $4,000 in assets for an individual; and $1,187/month income and $6,000 in assets for a couple. QMB-eligible beneficiaries must go to medical care providers who participate in the Medical Assistance Program. In addition to the income and assets stated, an individual or couple may have a house, car, and a burial plan, and still be eligible for the QMB Program. Applications are made for the QMB Program through the local Departments of Social Services or Baltimore County Department of Aging. QMB recipients receive a gray card as evidence of their eligibility. 

Specified Low-Income Medicare Beneficiary Program (SLMB)

Also known as SLMB or SLIMBY, this program will pay the Medicare Part B premium ($96.40 per month in 2009 for people whose income is slightly more than the QMB criteria. The current SLMB eligibility guidelines are: $1,060 - 1,190 month income and $4,000 in assets for an individual and $1,420 -1,595/month income and $6,000 in assets for a couple. As with the QMB Program, an individual or couple may hold certain assets (house, car, burial fund, etc.) which may be exempt from consideration. Applications are made for the SLMB Program through the local Departments of Social Services or Baltimore County Department of Aging. Eligibility guidelines become effective April 2009.

Back to Top

Protection from Spousal Impoverishment Program

This amendment applies to couples when one spouse begins a continuous period of residence in a nursing home on or after September 30, 1989, and subsequently applies for Medicaid. All non-exempt assets (savings and checking accounts, stocks, bonds, etc.) owned by either spouse, jointly or separately, are pooled as of the date of institutionalization. 

The "community spouse" may keep $20,880 or 1/2 of the assets, whichever is greater, but not more than $104,400.  The couple's remaining assets are used to pay for nursing home care or other eligible expenses, until the institutionalized spouse's assets reach the Medicaid eligibility level of $2,500. The "community spouse's" income will be evaluated to determine how much, if any, of the institutionalized spouse's monthly income can be allowed for the community spouse's monthly maintenance allowance. 

This maintenance allowance will supplement the community spouse's own income up to $1,711/month. If shelter expenses alone exceed $513/month (30 percent of $1,711,) an additional amount, equal to the excess, will be allowed.  The maximum total allowance cannot exceed $2,610/month. 

The institutionalized spouse also is allotted an allowance of $40/month. A family allowance may be made if there is a dependent child, parent, brother or sister of either spouse residing with the community spouse, in the amount of 1/3 of the community spouse's maintenance allowance less any income of the dependent individual, for each dependent family member. 

Local Departments of Social Services are responsible for evaluating a couple's income and assets and determining eligibility.

As of January 2006, the Medicare Prescription Drug Program will offer coverage to everyone with Medicare. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. You choose the drug plan. Although premiums and deductibles may vary according to the plan, in general they will be similar to the following:

• You will pay a premium average of around $30.36 per month.
• You will pay the first $295 (a deductible) the beginning of each year.
• You will pay about 25 percent of covered prescription drug costs from $295 to $2,700.
• You will pay 100 percent of the costs between $2,700 until you reach $6,153.
• You will pay 5 percent of covered prescription drug costs over $6,153.
• At the catastrophic level of $6,153, you will have spent $4,350 in out-of-pocket costs.

Each plan will have its own list of covered drugs, called a formulary list. You can apply for the New Medicare Prescription Plan by making a list of your drugs then call 1-800-MEDICARE which is 1-800-633-4227 or visit www.medicare.gov. By giving them your zip code and list of your drugs, they will tell you which Medicare Prescription Drug Plan covers all your drugs and will best fit your needs.

You will qualify for extra help to pay premium, deductible and co-payments if you are single and have an income level below $15,600, and a resource value of $12,510 or less. For couples, if your income is below $21,000 and your resources are below $25,510. In order to apply for the extra help, individuals will need to fill out an application from Social Security or apply online at www.ssa.gov. 

Call Senior Information and Assistance at 410-887-2594 for additional information.

Back To Top

Revised December 3, 2008