Work Incentives Working Group

State Public Benefits Manual

Returning to Work:
Questions and Answers for People Recieving SSI and/or SSDI

 

State Public Benefits Manual

CHAPTER FIVE
MEDICARE

A. INTRODUCTION

Medicare is a federally-funded health insurance program for seniors and some people with disabilities. Medicare covers most hospital and physician costs, but not the cost of prescription drugs. Most people on Medicare must pay premiums, annual deductibles, and co-payments for their health care. Most individuals receiving SSDI benefits will have Medicare as their primary insurance.

B. ELIGIBILITY FOR MEDICARE

The following groups of people are eligible for Medicare:

Eligible Seniors

  • Anyone over 65 years of age who gets a Social Security Retirement or Railroad Retirement benefit.
  • Anyone over 65 years of age who receives SSI (Supplemental Security Income) benefits.
  • Certain retired federal employees covered under the Federal Health Benefit Act.

Eligible People with Disabilities

  • Any person who gets Social Security Disability Insurance benefits, beginning with the 25th month for which they receive benefits.
  • Disabled widows and widowers between the ages of 50 and 65, who receive a check based on their spouse's work history, beginning with the 25th month for which they receive benefits.
  • Disabled adults age 18 and over who receive Social Security Disability benefits for a disability that began before age 22, beginning with the 25th month of benefits.
  • People who need dialysis or a kidney transplant for end-stage kidney disease.

C. APPLYING FOR MEDICARE

Most people receiving Social Security or Railroad Retirement benefits are automatically enrolled in Medicare when they become eligible. Other eligible individuals must enroll at their local Social Security Office. People can enroll in Part B coverage (see below), only during certain enrollment periods. The most important enrollment periods are:

  • In the three months before a person turns 65 and the four months afterwards;
  • Between January 1 and March 31 each year.

People who do not choose Part B coverage when it is first available to them usually must pay an increased Part B premium if they choose to enroll in Part B later on.

D. MEDICARE COSTS AND EXPENSES

Most people on Medicare pay a monthly premium of $50.00 (2001 figure) for their Part B Medicare coverage (see below for a discussion of Medicare Parts A and B). People who receive a Social Security or Railroad Retirement check will normally have the Part B premium deducted from their check. Other people will be billed quarterly for the Part B premium.

Part A coverage is free for the great majority of Medicare beneficiaries.

There are also deductibles and co-payments associated with Medicare coverage. The annual hospital deductible (Part A) for 2001 is $792 for the first 60 days. There is also a co-insurance charge for days of hospitalization after 60 days’ $198 per day for the 61st-90th day each benefit period, and $396 per day for the 91st-150th day for each lifetime reserve day (total of 60 non-renewable lifetime reserve days). The annual out-patient deductible (Part B) is $100. People receiving out-patient services under Part B are also liable for co-payments equal to 20% of the Medicare approved amount for the service. Many people have supplemental insurance which pays these deductibles and co-payments, either from private insurance carriers or through the Illinois Department of Human Services (see below). People who choose to join Medicare Health Maintenance Organizations do not have these co-payments or deductibles.

E. MEDICARE COVERAGE

Medicare consists of two distinct types of coverage called Part A and Part B. Each covers different types of services.

Medicare Part A (100% payment after annual deductible unless noted otherwise)

  • Hospital care (including psychiatric hospital care-- additional co-payments apply after 60 days)
  • Skilled nursing facility care (up to 100 days maximum, additional co-payments apply after 20 days)
  • Skilled home health care and related services, including durable medical equipment and supplies (80% coverage on durable medical equipment)
  • Hospice Care

Medicare Part B (80% coverage after annual deductible)

  • Doctor's services, (both in-patient and out-patient)
  • Rehabilitation therapy, including physical therapy and speech therapy
  • Durable medical equipment
  • Diagnostic tests
  • Clinical laboratory services
  • Outpatient hospital care
  • Ambulance services
  • Home health services
  • Some preventive health services, including flu shots, mammograms, colorectal cancer screening, diabetes monitoring, and pap smears ($100 annual deductible does not apply to some of these services)

F. MEDICARE MANAGED CARE

Medicare beneficiaries who choose to enroll in a Health Maintenance Organization (HMO) generally do not have to pay Medicare co-payments and deductibles. In addition, some Medicare HMOs also offer additional services, such as additional preventive health care or limited prescription drug benefits. In return, as with any managed care plan, services are generally covered only if provided by providers within the HMO and under referral from the patient's primary physician. People who are in a Medicare managed care plan may disenroll at any time, but then may have only limited rights to enroll in another managed care plan or to purchase Medicare supplemental insurance.

A Medicare HMO may be helpful to an individual if the HMO has good prescription drug coverage. Make sure, however, that the prescription coverage is sufficient for the individual's needs and that their doctor is a member of the HMO. Also check for any limitations on any mental health treatment.

G. HELP IN PAYING FOR MEDICARE COSTS

The Illinois Department of Public Aid will pay the out-of-pocket costs for some low-income persons who have Medicare under the following programs.

Qualified Medicare Beneficiary (QMB)

Under the Qualified Medicare Beneficiary (QMB) program, the Illinois Department of Public Aid will pay the Medicare Part B premium and Medicare deductibles and co-payments for many individuals who have Medicare whose countable incomes are below the federal poverty level.

Persons are eligible if they:

  • are receiving Medicare Part A benefits;
  • are a U.S. citizen or immigrant eligible for Medicaid (see discussion of immigrant eligibility for Medicaid in Chapter Three);
  • have countable monthly income equal to or below 100% of the federal poverty level (FPL)(see table below); and
  • have countable assets under $4,000 for one person and under $6,000 for two or more persons.

Specified Low Income Medicare Beneficiary (SLIB)

If a person's monthly income is too high to qualify for QMB, he/she may still be able to have the Department of Public Aid pay for the monthly Medicare Part B premium. This program is called Specified Low Income Medicare Beneficiary (SLIB). Persons qualify for SLIB if they meet all the eligibility requirements except that their countable monthly incomes are between 100% but no more than 120% of the federal poverty level (FPL). The table below is based on the 2001 FPL.


SMIB Buy-In Program

In addition to paying for Medicare Part B premiums for QMBs and SLIBs, the Department of Public Aid will enroll in Medicare Part B and pay the Part B premiums for persons who are receiving AABD cash benefits or who receive both regular medical benefits and SSI.

Qualified Individual 1 (QI-1) Program

If a person's monthly income is too high for QMB or SLIB coverage, he/she may still be able to have the Department of Public Aid pay for the monthly Medicare Part B premium. This is called the Qualified Individual 1 (QI-1) program. Persons qualify for the QI-1 program if they meet all eligibility requirements except that their countable monthly income is over 120%, but no more than 135% of the federal poverty level and they are not eligible for Medicaid. A person enrolled in a spenddown is not considered eligible for Medicaid and may be eligible for QI-1 benefits.

Qualified Individual 2 (QI-2) Program

Certain persons receiving Medicare whose monthly countable income is over 135%, but no more than 175% of the federal poverty level, may be eligible for a monthly cash benefit that is issued once per year. The monthly benefit, as of 2000, is $2.87 per month - $34.44 per year and is issued by DHS’s Springfield office.

**Note** Individuals who are eligible for QMB or SLIB do not have prescription drug coverage. It is possible to be eligible for both Medicare and Medicaid (which would cover the prescription drugs). Make sure your clients apply for a medical card (AABD) and check to make sure that the calculations of income were done correctly.

Applying

A person can request an application by calling the Department of Human Services (DHS) by calling 1-800-252-8635 or the Department of Aging (DOA) at 1-800-252-8966.The application must be filed at the local IDHS office. Only medical providers who have enrolled in Medicaid and accept Medicare assignment to be paid for services provided to QMBs.

A recent IDHS Manual Release on QMB, SLIB, and QI is included in the Appendix.

H. LEARNING MORE ABOUT MEDICARE

The federal Medicare regulations are found at 42 CFR, Subchapter B, parts 405 et seq. There are also extensive resources, including all of the regulations, available on-line, including at the following sites:

www.medicareinfo.com
www.ssa.gov
www.hcfa.gov
www.medicare.gov

 

 

BACK TO TOP

CHAPTER ONE
SOCIAL SECURITY DISABILITY PROGRAMS

CHAPTER TWO
HOW TO WORK AND MAINTAIN SOME SSDI OR SSI BENEFITS

CHAPTER THREE
STATE ADMINISTERED BENEFITS

CHAPTER FOUR
HOW THE MEDICAL ASSISTANCE PROGRAMS WORK

CHAPTER FIVE
MEDICARE

CHAPTER SIX
OTHER STATE AND LOCAL PROGRAMS THAT PROVIDE CASH OR MEDICAL ASSISTANCE

CHAPTER SEVEN
FOOD STAMPS

CHAPTER EIGHT
OFFICE OF REHABILITATIVE SERVICES (ORS)

CHAPTER NINE

OTHER BENEFITS AND/OR PROTECTIONS