Medicare/ Medicaid and Senior Health Insurance
Questions & Answers

Click to jump down to questions & answers on:

Medicare & Medicaid: What's the Difference? | Medicaid Details | Medicare Details | Help with Medicare Expenses | Health Insurance Information/ Choosing a Medicare Supplement | How to Stop Medicare & Medicaid Fraud

Medicare & Medicaid: What's the Difference?

Q: I hear people talk about Medicare and Medicaid. Are these different programs?

A: Congress created both Medicare and Medicaid in 1965. The programs have different eligibility requirements and different benefits. Many people confuse Medicare with Medicaid because the names sound alike and the programs are available to some of the same groups of people.

Q: How does eligibility for two programs differ?

A: Both Medicare and Medicaid are directed to those age 65 or older and many younger people with disabilities. Medicare is available regardless of income and resources. Medicaid eligibility is available only to individuals who meet certain income and resource limits. Medicaid has many different programs. Each has its own income and resource limits. A Medicare beneficiary with limited income and resources may also be eligible for Medicaid assistance.

Medicaid Details

Q: What is covered by Medicaid?

A: Medicaid is an assistance program that pays certain medical and health care cost of persons who qualify. Medicaid has many different programs. Benefits vary depending on the program. Some Medicaid programs pay for services not covered by Medicare such as prescription drugs, dental care, eyeglasses, hearing aids, and long-term care. Other Medicaid programs are more limited and pay only for Medicare premiums, deductibles and coinsurance. Generally, someone eligible for Medicaid does not need Medicare supplement insurance.

Q: I need help and think I qualify for Medicaid. Where do I go to apply?

A: Iowa's Medicaid program is funded by the federal and state government and is managed by the Iowa Department of Human Services (DHS). To determine if you qualify for Medicaid, contact your local county office of human services. A listing of local offices can be found on the Internet at http://www.dhs.state.ia.us/dhs2005/dhs_homepage/docs/clickable_map.html. The phone number for your local office is available in the "local government" section of your telephone directory. To receive assistance in completing the paperwork, contact your local Area Agency on Aging.

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Medicare Details

Q:What are the benefits under Medicare?

A: Medicare consists of two parts, Part A and Part B. Medicare Part A is hospital insurance and is free to most who are eligible for Medicare. Medicare Part B is medical insurance and costs $58.70 per month for 2003. Medicare covers medically necessary services for illnesses and injuries. Medicare rules determine how much can be charged for covered services. A Medicare beneficiary is responsible for $100 deductible per calendar year, 20% coinsurance of Medicare approved amount (except the coinsurance is waived for clinical lab services and flu and pneumonia vaccines), and services not covered such as prescription drugs, annual physicals, routine vision services or hearing exams. Most Medicare beneficiaries have supplemental insurance to cover some of these costs.

Q: Where do I get answers to questions about Medicare?

A: Whether you are new to Medicare or have had Medicare for a long time, you may have questions about what is covered. Much information is available on the Internet at http://www.medicare.gov. You can also get a free copy of the Medicare Handbook by calling the Social Security Administration at 1-800-772-1213. For coverage and claims questions on Medicare Part A (hospital insurance), which covers hospitals, skilled nursing facilities, home health visits, or hospice services, contact (1-877-910-8139) Cahaba Government Benefit Administrators (GBA). For questions on Medicare Part B, which covers such things as doctors' services, ambulances and lab tests, call Noridian Government Services, Inc. at 1-800-532-1285. Part B also covers durable medical equipment, such as a walker or oxygen equipment. For more information, call CIGNA at 1-800-899-7095.

Q: Does Medicare cover the cost of prescription drugs?

A: Currently, the answer is no. The state of Iowa currently has a prescription discount program called Iowa Priority, and other resources may be available to reduce your prescription drug costs. Follow the link above for details about Iowa Priority. The Senior Health Insurance Information Program (SHIIP) may also be helpful by helping you to find discounts on medications.

Q: Can I appeal a Medicare decision?

A: Yes. An appeal must be filed within 120 days after Medicare makes a decision on a claim. The Senior Health Insurance Information Program (SHIIP) is available to assist you in filing an appeal.

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Help with Medicare & Other Medical Expenses

Q: How can I get help with Medicare expenses?

A: There is a Medicaid program for people who need help with Medicare expenses called the Qualified Medicare Beneficiary (QMB) Program. This program is for people who are elderly or disabled and who have a low income -- this includes Social Security, wages, pensions, interest payments and dividends and few resources -- including cash and other things they own. Some things like a home, (including the property and furnishings) may not count. Under the QMB Program, Medicaid pays Medicare premiums, deductibles and co-insurance for persons who are qualified Medicare beneficiaries. For more information regarding the QMB program, contact the Senior Health Insurance Information Program (SHIIP).

Q: What if my income is too high to qualify for the QMB Program?

A: You may qualify for the "Specified Low-Income Medicare Beneficiary Program" "SLMB" for short. SLMB pays your Medicare Part B premium only. It has the same qualifications as the QMB program, except is has higher monthly income limits. For more information on the SLMB program, contact the Senior Health Insurance Information Program (SHIIP).

Q: I have high medical expenses, what can I do?

A: The Medically Needy Program might be an option. This is a Medicaid program designed to provide medical coverage for you if you have limited income or high medical expenses that use up most of the income. For more information, contact your local County Department of Human Services.

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Health Insurance Information

Q1: I have questions about medical bills and insurance claims, where can I get help?

Q2: I need help figuring out what type of Medicare supplement or long term care insurance is right from me. Is there anyone who can help me?

Q3: I'm retired, but not yet eligible for Medicare. What are my health insurance options?

A: Call the Senior Health Insurance Information Program (SHIIP) when you need information on health insurance issues. SHIIP is a service of the State of Iowa Insurance Division and has trained insurance counselors/volunteers. No one associated with SHIIP sells insurance and all assistance is free. Especially of interest may be the SHIIP fact sheet "Getting Ready to Retire: Health Insurance Issues", which is available on-line. Follow the link above for more details.

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Q1: I suspect Medicare fraud but don't know how to report it.

Q2: How can I protect my Medicare/Medicaid numbers from persons who want to scam these programs?

A: If you want to report suspected Medicare waste, fraud, or abuse, or to learn about identity protection, call the Operation Restore Trust hotline at 1-800-432-2449. The hotline is available statewide. More information on this program is available in the Operation Restore Trust section of the advocacy page.

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