Introduction

The basic health insurance program under Medicare consists of two parts:

• Part A – Hospital Insurance
  You are automatically enrolled for hospital insurance.
• Part B – Medical Insurance
  Because medical insurance benefits are generally provided only for services in the United States, you are not automatically enrolled for this part. You may apply if you want Part B medical insurance.

Both hospital and medical insurance benefits are described in this leaflet.

Part A - Hospital Insurance

Medicare provides hospital insurance benefits for railroad retirement beneficiaries and certain members of their families who are:

• Age 65 or older, or
• Under age 65 and totally disabled for at least 24 months.

Persons who qualify for Medicare are entitled to hospital insurance benefits for covered hospital and post-hospital services furnished in Canada and the United States.

Your Medicare card shows the date your hospital insurance coverage begins.

Hospital insurance will help pay for part of the following services:

• Inpatient Hospital Benefits help pay for hospital care for up to 90 days during each “benefit period.” A benefit period begins on the first day you receive covered services as a patient in a hospital and ends after you have been out of a hospital or skilled nursing facility for 60 consecutive days. You may be discharged and readmitted several times during a benefit period, but a new benefit period cannot begin until you have not been a patient in any hospital or skilled nursing facility for 60 consecutive days.
  
  If you need more than 90 days of hospital care in any benefit period, you can draw on 60 “lifetime reserve” days. Each lifetime reserve day used permanently reduces the total you have left.
   
• Skilled Nursing Facility Services help pay for up to 100 days of extended care during a benefit period if (1) you were in a hospital for at least 3 days, and (2) your medical needs require daily skilled nursing or rehabilitation care, and (3) a doctor determines that you need extended care and orders your care, and (4) you are admitted within a limited period, generally 14 days, after you leave the hospital, and (5) you are admitted for further treatment of a condition for which you were treated in the hospital.
   
• Home Health Benefits cover home health visits, under certain conditions, by nurses or other health workers from qualified home health agencies. Hospital insurance pays for up to 100 visits in the 1-year period following your most recent discharge from a hospital or skilled nursing facility if (1) you were hospitalized for at least 3 days, and (2) your physician arranges for the services within 14 days after your discharge, and (3) you are treated for a condition for which you were treated in the hospital or skilled nursing facility.

Payments for services furnished in Canada are reduced by whatever is payable for those services under Canadian law. In other words, the benefits are limited to the amount by which Medicare hospital insurance benefits exceed the amount payable under Canadian Provincial plans.

Covered Services

Covered services in a hospital or skilled nursing facility include the cost of room and meals (including special diets) in a semiprivate room (2 to 4 beds), regular nursing services, and services in an intensive care unit of a hospital. They also include the cost of drugs, supplies, appliances, equipment, and any other services ordinarily furnished to inpatients of the hospital or skilled nursing facility.

Covered home health benefits include part-time skilled nursing care, physical therapy, and speech therapy. If you need skilled nursing care or physical or speech therapy, Medicare will also help pay for occupational therapy and for medical supplies and appliances furnished by the home health agency.

Services Not Covered

Hospital insurance will not pay all of your health care bills. Hospital insurance does not cover:

• Doctor bills.
• Private duty nurses.
• Convenience items, such as the cost of a telephone or television in your room.
• Custodial care – care which is primarily to help with personal daily needs such as bathing, eating, and dressing.

How to Claim Benefits

Complete Form AA-104 to claim benefits for covered services you receive in Canada. Mail the completed form to the Railroad Retirement Board along with your receipted bills for the services. If none of the charges for the services were paid under the Provincial hospital plan, you must also attach a statement signed by your doctor certifying that the services furnished were medically necessary.

If you receive services covered by Medicare hospital insurance and the services are furnished in the United States, do not file Form AA-104. Just show your Medicare card to the people at the place where you receive services. They will handle the claim for payment.

Part B - Medical Insurance

Except on rare occasions, Medicare medical insurance does not pay for medical services furnished in Canada. Medical payments are limited to services in the United States. The exceptions are medical services required for (1) emergencies occurring while traveling between Alaska and another state of the United States, and (2) emergencies occurring in the United States with services rendered in a nearby Canadian hospital.

The services covered under medical insurance in the United States include:

• Physician’s and surgeon’s services in the hospital, doctor’s office, home, or elsewhere.
• Limited chiropractic services.
• Up to 100 home health visits under an approved plan each year with no need for prior hospitalization. This is in addition to the 100 visits provided under the hospital insurance program.
• Other medical and health services, such as diagnostic services, X-ray or radioactive treatments, surgical dressings and splints, coasts, and rental or purchase of medical equipment.
• Drugs a doctor administers as part of his or her professional services which cannot be self-administered.
• The full approved charges for laboratory, X-ray or other radiology services furnished by physicians while you are an inpatient at a hospital.
• Outpatient physical therapy services – whether or not you are homebound – furnished under the supervision of a participating hospital, skilled nursing facility or home health agency, or an approved
  clinic, rehabilitation agency, or public health agency.
• All covered outpatient hospital benefits whether for diagnosis or treatment.
• Certain services by podiatrists.
• Certain ambulance services.

Services Not Covered

Medical insurance does not cover the cost of some services such as most routine physical check-ups, drug prescriptions, eye glasses, hearing aids, and ordinary dental treatment.

When You Can Enroll

To get medical insurance, you must sign up for it during specific enrollment periods set by law. Your initial enrollment period begins three months before and extends three months after the month you reach age 65 or have been totally disabled for at least 24 months.

If you want Medicare medical insurance and you want to be sure your coverage begins as soon as you are eligible, you need to sign up before the hospital insurance effective date on your Medicare card. If you do not enroll in the first three months of your initial enrollment period, the start of your medical insurance will be delayed from 1 to 3 months after you enroll.

If you do not sign up during your initial enrollment period, you can sign up during a general enrollment period. A general enrollment period is January 1 through
March 31 of each year. If you wait until then to enroll, you may have to pay a higher monthly premium for the same protection, and your coverage will not begin until the following July 1.

Should You Enroll

Since medical insurance is voluntary, you will have this coverage only if you enroll for it. In making your decision, you should consider these facts:

• If you will not be coming to the United States in the future – either to live or to receive medical services – it is not to your advantage to enroll for medical insurance. Medical insurance generally pays only for services received in the United States.

• On the other hand, if you expect to come to the United States – either to live or to receive medical care – you should consider signing up for medical insurance.

Dropping Medical Insurance

If you decide to drop out of the medical insurance program, you can do so at any time. Your coverage will stop at the end of the next calendar quarter. You will continue to have hospital insurance coverage. If you drop out, you can re-enroll during a general enrollment period (January, February and March of each year). There is no limit to the number of times you can enroll during your lifetime.

Paying for Medical Insurance

If you are receiving a railroad retirement annuity, your medical insurance premiums will be deducted from your monthly payments when your coverage begins. If you are not receiving monthly benefits, you will be billed for the premiums every three months.

The amount of the monthly premium you will pay if you enroll now for medical insurance is shown on the enclosed card. The premium rate is subject to change each year.

How to Claim Benefits

In order to enroll for medical insurance, complete the enclosed application card and return it using the enclosed envelope.

• If you sign by mark (X), also have someone who knows you sign his or her name and enter their address in the space provided on the card.
• If you are receiving benefits as a representative payee, sign your name. For example, if the card is addressed “Bill Jones for John Smith,” Bill Jones should complete and sign the card.
• If the card is addressed to an institution, an authorized official of the institution should complete and sign the card. The official should also show his or her title.

If You Do Not Want Medical Insurance

If you do not want medical insurance, simply destroy the enclosed application card and envelope. No other action is needed.

Your Medicare Card

Your Medicare card shows that you have hospital insurance. If you sign up for medical insurance, we will mail you a new card showing you have both hospital and medical insurance.

Your Medicare card shows your personal claim number and is for your use only. When a husband and wife both sign up, each receives a Medicare card and claim number.

If you lose your card, let us know so that we can mail you a new one.

Questions?

This leaflet does not give all the details about your coverage under Medicare. If you have questions which the leaflet does not answer, you may write to:

Railroad Retirement Board
844 Rush Street
Chicago, IL 60611
U.S.A.