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Medicare 2019 Fact Sheet

Medicare Monthly Premiums 2019

Part A Premium

Most individuals are entitled to "premium-free" Part A benefits based on their or their spouse's work history. Individuals who have less than 40 quarters of Social Security coverage may be eligible to purchase Part A benefits at $437 per month (zero to 29 quarters) or $240 per month (30 to 39 quarters).

Part B Premium

The Part B premium will be $135.50 for two-thirds of all Part B enrollees in 2019. The 28 percent of individuals whose Social Security cost-of-living adjustment (COLA) was insufficient for them to pay the full $135.50 per month will be billed a lesser amount.

The Part B premium will be $135.50 per month in 2019 for those qualifying for the Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) programs. Individuals enrolled in QMB or SLMB in 2018 or 2019, but lost the program because their income increased or they failed to recertify, will pay $135.50 per month.

If an individual has an income over $85,000 or a couple has an income over $170,000, an income-related monthly adjustment amount (IRMAA) may apply and they will pay a higher Part B premium (and a higher Part D premium) each month. To find out more, call Social Security.

Part A Medicare Benefits

Inpatient Hospital Care

Inpatient hospital care includes a semiprivate room, meals, general nursing, and other hospital services and supplies. It 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 2019, a Medicare beneficiary is responsible for a deductible of $1,364 for the first day of each benefit period, after which Medicare pays for up to 60 days of full hospital care. For days 61 to 90, the beneficiary is responsible for $341 per day (co-payment). In addition, a beneficiary has 60 lifetime reserve days and would be responsible for a co-payment of $682 per day for days 91 to 150. There is no Medicare coverage for days 150 to 365.

Skilled Nursing Facility Care

A semi-private room, meals, skilled nursing, rehabilitative services, and other services and supplies are provided after a hospital stay of at least three consecutive days if ordered by the doctor. Medicare covers 100 days of skilled nursing or rehabilitative care in a Skilled Nursing Facility (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 one to 20 in full; the beneficiary is responsible for a $170.50 per day co-payment for days 21 to 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. Beneficiaries pay a co-payment of up to five dollars for outpatient prescription drugs and five 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

Home health care includes 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 care for two to three days a week up to four or six weeks. In exceptional cases, longer care may be provided. In order to be eligible, a beneficiary must meet all of 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
  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

Services

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

A Medicare beneficiary pays a $185 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 15 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 immunosuppressive drugs, post transplant, if the transplant was performed in a Medicare-approved facility and the patient is enrolled in Medicare Part A at the time of the transplant.

DMEPOS Affects Baltimore County

As of January 1, 2019, there will be a two-year gap in the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Program (DMEPOS). This means that in 2019 and 2020, Medicare beneficiaries on fee-for-service Medicare may purchase Medicare-covered Durable Medicare Equipment (DME) from any Medicare-enrolled supplier. During these two years, beneficiaries will not be limited to a competitive bidding supplier list. This change does not affect beneficiaries in Medicare Advantage plans, who must continue to get their Medicare-covered DME through in-network suppliers.

Effective July 1, 2013, all Baltimore County ZIP codes will be considered competitive bid areas (CBAs) for the following DMEPOS covered by Part B:

  • Oxygen, oxygen equipment and supplies
  • Standard power and manual wheelchairs, scooters, and related accessories
  • Continuous positive airway pressure devices (CPAPs) and respiratory assist devices, and related supplies
  • Hospital beds and related accessories
  • Walkers and related accessories
  • Negative pressure wound therapy pumps and related supplies
  • Support surfaces (mattresses and related supplies)

The goal of this program is to save Medicare and beneficiaries money while enhancing service. Potential suppliers submitted bids. The winning suppliers are called Medicare Contract Suppliers. If you live in or are visiting a CBA, you must purchase the above items from a Medicare Contract Supplier who serves the area if you would like Medicare to pay for it. The beneficiary would still be responsible for the Part B deductible and the 20 percent co-insurance. To determine if a ZIP code is in a CBA or to locate the Medicare Contract Suppliers for the CBA, call your local State Health Insurance Assistance Program (SHIP) at 410-887-2059 or call Medicare at 1-800-MEDICARE (1-800-633-4227), or visit the Medicare website.

DMEPOS not listed above may be purchased from any Medicare-approved supplier. Always ask the supplier if they accept Medicare "assignment" to ensure that you will not have to pay more than a 20 percent co-insurance.

National Mail-Order Program for Diabetic Testing Supplies

Beginning July 1, 2013, all diabetic testing supplies that are delivered to the home need to be purchased from National Mail-Order Contract Suppliers for Medicare to pay for the items. This change decreases the amount Medicare and beneficiaries pay for these items while ensuring the quality of the program. You may elect to purchase your supplies at a local store (pharmacy or storefront supplier), but be sure they are Medicare-approved suppliers who accept assignment. Local stores that do not accept assignment may charge more than the 20 percent co-insurance.

Preventive Health Benefits

  • "Welcome to Medicare" visit during the first 12 months on Medicare Part B. Medicare pays 100 percent.
  • Annual wellness visit. Medicare pays 100 percent.
  • Beneficiaries 40 years of age and older are entitled to one screening mammogram every year. Medicare will pay a maximum of 100 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 individuals at high risk, Medicare provides coverage (100 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 pay 80 percent for glaucoma screenings once every 12 months for individuals at risk for glaucoma, including people with diabetes or a family history of glaucoma.
  • Medicare covers 100 percent of flu vaccinations once a year, a pneumonia vaccination once in your lifetime and a hepatitis shot for high-risk individuals.
  • Medicare covers 100 percent of diabetic screenings, up to one to two tests per year depending on your risk level.
  • Medicare covers 100 percent of blood test screenings for cholesterol, lipid and triglycerides levels once every five years.
  • Medicare may cover 100 percent for medical nutritional therapy if you have diabetes or kidney disease, and your doctor refers you.
  • Medicare pays 100 percent for one abdominal aortic aneurysm screening if referred during the "Welcome to Medicare" visit.
  • Medicare pays 100 percent for an annual alcohol misuse screening and up to four face-to-face counseling sessions with a qualified primary doctor or provider.
  • Medicare pays 100 percent annually for a depression screening done in a primary care setting.
  • Medicare pays 100 percent for one EKG screening if referred at the "Welcome to Medicare" visit.
  • Medicare pays 100 percent for HIV screening on an annual basis, unless pregnant.
  • Medicare pays 100 percent for an obesity screening done once a year by primary care providers and for face-to-face counseling (call for details).
  • Medicare will pay 80 percent for diabetes self-management training with a written order from a provider.
  • Medicare will pay 80 percent for diabetic supplies—blood sugar test strips, testing monitors, lancets and test solution.
  • Medicare will pay 100 percent for smoking cessation by a qualified professional.

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 three pints of blood if you cannot replace them in some manner
  • Routine physical exams including most presurgical 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 that 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)

Important Related Subjects

Qualified Medicare Beneficiary Program

The QMB program, also known as "quimby," will pay the Part B premium ($135.50 per month in 2019), deductibles and coinsurance payments of the Medicare Program for older persons, and persons with disabilities, who are financially eligible. The current QMB eligibility guidelines are:

  • $1,061 per month income and $9,230 in assets for individuals
  • $1,430 per month income and $14,600 in assets for couples

QMB-eligible beneficiaries must go to medical care providers who accept Medicare and QMB. In addition to the income and assets stated, an individual or couple may have a house (in which they live) and a car. The asset level includes a $1,500 per person burial plan. Applications are made for the QMB program through the local Departments of Social Services or the Baltimore County Department of Aging. QMB recipients receive a gray card as evidence of their eligibility.

Specified Low-Income Medicare Beneficiary Program

The SLMB program, also known as "slimby," will pay the Medicare Part B premium ($135.50 per month in 2019) for people whose income is slightly more than the QMB criteria. The current SLMB eligibility guidelines are:

  • $1,062 to $1,426 monthly income and $9,230 assets for individuals
  • $1,431 to $1,923 monthly income and $14,600 assets for couples

In addition to the income and assets stated, an individual or couple may have a house (in which they live) and a car. The asset level includes a $1,500 per person burial fund. Applications for the SLMB Program are made through the local Departments of Social Services or the Baltimore County Department of Aging.

Medicare Prescription Drug Plan

As of January 2006, the Medicare Prescription Drug Program offers 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 for 2019:

  • You will pay a premium ranging from $14 to $97.20 per month.
  • You may pay the first $415 (a deductible) at the beginning of each year.
  • You will pay about 25 percent of covered prescription drug costs from $415 to $3,820.
  • You will pay 25 percent of brand drugs and 37 percent of generic drugs in the coverage gap ($3,820 to $7,653).
  • You will pay five percent of very low cost drugs: $3.40 for generic and $8.50 for brand in the catastrophic level.

Each plan has a list of covered drugs called a formulary list. To apply for the Medicare Prescription Plan, call 1-800-MEDICARE (1-800-633-4227) or visit the Medicare website. Provide your ZIP code and list of drugs to find out which Medicare Prescription Drug Plan covers all your drugs and will best fit your needs. Or you may contact Baltimore County's SHIP Office at 410-887-2059 for assistance. In addition, the SHIP staff will be assisting Medicare beneficiaries by appointment at area senior centers on a one-on-one basis during Part D open enrollment from October 15 through December 7.

To qualify for extra help to assist with payment of the Medicare Part D premium, deductible and co-payments, you must meet the following requirements:

  • An income level below $18,975 and a resource value of $14,390 or less for individuals
  • An income level below $25,605 and a resource value of $28,720 or less

To apply for the extra help, fill out an application from Social Security or apply online at the Social Security Administration website.

To qualify for the Maryland Senior Prescription Drug Assistance Program, you must meet the following requirements:

  • An income level below $37,470 for individuals
  • An income level below $50,730 for couples

Assets are not counted. To apply, call SHIP at 410-887-2059 for an application.

Call Maryland Access Point of Baltimore County (formerly Senior Information and Assistance) at 410-887-2594 for additional information.

 
Revised March 20, 2019         

 

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