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.
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