State Public Benefits Manual
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
B. ELIGIBILITY FOR MEDICARE
following groups of people are eligible for Medicare:
Eligible People with Disabilities
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:
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)
Medicare Part B (80% coverage after annual deductible)
F. MEDICARE MANAGED CARE
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
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
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)
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:
Specified Low Income Medicare Beneficiary (SLIB)
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.
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.
Individual 1 (QI-1) Program
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.
Individual 2 (QI-2) Program
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 DHSs
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.
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.
recent IDHS Manual Release on QMB, SLIB, and QI is included in the Appendix.
H. LEARNING MORE ABOUT MEDICARE
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: