Social Security, Medicare and more
by Barbara Richardson
et's talk about Medicare and Social Security, the most common assistance programs for the elderly. Many people with these benefits and their caregivers do not understand what is covered or how to use them, nor do they realize their rights. Many people are being denied the help they are entitled to and need simply from lack of information.
Social Security replaces only about 42 percent of an average wage earner's salary. Full retirement benefits are now payable at age 65, with reduced benefits available as early as age 62. The age for full benefits will gradually rise in the next century, until it reaches age 67 in 2027 for people born in 1960 or later. (Reduced benefits will still be available at age 62.)
Married workers can receive benefits based either on their own work record or their spouse's, whichever is higher.
You can find out how much you can expect to get from Social Security by asking for a Personal Earnings and Benefit Estimate Statement (PEBES) request form. To order the PEBES request form, you can call 1-800-772-1213; "TTY" number is 1-800-325-0778, between 7 a.m. and 7 p.m. on business days.
Early in the week and early in month is the worst time to call if you want fast service. You can call ANYTIME 365 days a year (except the TTY line). You can also skip the phone hassle and go directly to the Social Security Administration home page.
You can also request these helps:
- Understanding Social Security (Publication No. 05-10024)
- Retirement Benefits (Publication No. 05-10035)
- Survivors Benefits (Publication No. 05-10084)
- Disability Benefits (Publication No. 05-10029)
- Medicare (Publication No. 05-10043)
- Your Taxes... What They're Paying For... Where The Money Goes (Publication No. 05-10010)
- Your Number (Publication No. 05-10002)
Medicare comes in two "parts": Part A is standard coverage for Medicare;
Part B is an additional coverage provided for a monthly fee. Medicare A and B help pay for many medical needs:
- Outpatient hospital services
- X-rays and laboratory tests
- Ambulance transportation
- Breast prostheses following a mastectomy
- Services of certain specially qualified practitioners who are not doctors
- Physical and occupational therapy
- Speech language pathology services
- Home health care, if you do not have Part A of Medicare
- Blood, after the first three pints
- Flu, pneumonia and hepatitis B shots
- Pap smears for the detection of cervical cancer
- Mammograms to screen for breast cancer
- Outpatient mental health services
- Artificial limbs and eyes
- Arm, leg, back and neck braces
- Durable medical equipment, including wheelchairs, walkers, hospital beds and oxygen equipment prescribed by a doctor for home use
- Kidney dialysis and kidney transplants. Under limited circumstances, heart and liver transplants in a Medicare-approved facility
- Medical supplies and items such as ostomy bags,
surgical dressings, splints and casts
Some common needs are not covered such as:
- Dental care
- Routine foot care
- Hearing aids
- Prescription drugs (with a few exceptions)[Note: This article was written before the recent Medicare prescription drug package passed by Congress--Ed.]
- Eyeglasses (unless corrective lenses are needed after cataract removal)
When in doubt about whether a service or need is covered by Medicare, call your Medicare carrier.
Medicare and health care facilities
Besides helping to pay for care in a hospital or skilled nursing facility, Medicare covers a variety of services provided at special types of health care facilities:
- Ambulatory Surgical Center--when your surgery does not require a hospital stay.
- Rural Health Clinics--serve areas where few people live.
- Comprehensive Outpatient Rehabilitation Facility (CORF) (only Part B)--outpatient rehabilitation facility if prescribed by a doctor.
- Community Mental Health Centers (only part B)--outpatient mental health care.
- Federally Qualified Health Centers--these facilities are mainly community health centers.
- Certified Medical Laboratory--diagnostic tests.
Help for low-income Medicare beneficiaries
If you are a Medicare beneficiary with a very low income (around $700 a month) and few assets, you might qualify for state assistance in paying your health care costs. Two examples are the Qualified Medicare Beneficiary (QMB) program and the Specified Low-Income Medicare Beneficiary (SLMB) program.
For more information contact your state or local Medicare, public welfare or social services office. You can find the number in the telephone directory under "State Government."
HELP, I am lost!
If you have questions about your eligibility or your loved one's eligibility for Medicare, call the Social Security Administration at 1-800-772-1213. The Social Security Administration treats all calls confidentially. Or call the Health Care Financing Administration in your area. Look in the government pages of the phone book.
--Federal law prohibits a doctor who does not accept assignment from charging more than 15 percent above Medicare's approved amount. Any overcharges must be refunded. This limit is even stricter depending in which state you reside.
--Doctors who do not accept assignment for elective surgery are required to give you a written estimate of your costs before the surgery if the total charge will be $500 or more. If you are not given a written estimate, you are entitled to a refund of any amount you paid in excess of the Medicare-approved amount for the surgery performed.
--A doctor who does not participate in Medicare and who provides you with a service that he or she knows or has reason to believe Medicare will determine to be medically unnecessary, and thus will not pay for, must tell you that in writing before performing the service. If written notice is not given, and you did not know that Medicare would not pay, you cannot be held liable to pay for that service. You do have to pay if you did receive written notice and signed an agreement to pay for the service.
--To avoid excess charges go to doctors and medical suppliers who accept assignment of Medicare claims. They are called participating doctors and suppliers. You can get list of participating doctors and suppliers by calling your Medicare carrier.
--Every time you go to the doctor for a service covered by Medicare you should receive a statement called an Explanation of Medicare Benefits (EOMB). It shows what was billed, the amount Medicare approved, and what you owe.
--If Medicare denies payment for health care services you received or pays less for those services than you think it should, you may have a right to appeal. (More information about the appeal process may be obtained from a Medicare intermediary or carrier in your state)
--Medicare pays the same way for a second opinion as it pays for other doctor services as long as you are seeking advice for the treatment of a medical condition covered by Medicare. If the first two opinions contradict each other, Medicare will help pay for a third opinion.
--In some cases Medicare covers the services of certified registered nurse anesthetists, certified midwives, nurse practitioners, physician assistants, clinical social workers and clinical psychologists.
--The Family and Medical Leave Act of 1993 has specific importance to children with aging parents. The law entitles employees (adult children) to take reasonable leave to care for a parent who has a serious health condition.
When Medicare and Social Security are not enough
There are programs that will help; the trick is knowing about them and where to go for information.
Free prescription medicine is available to those who qualify. If you do not have insurance or a government program that pays for your outpatient prescription medicines, or if the high cost of your medicine causes you a financial hardship, you may qualify. Call 1-573-778-1118 or go to http://www.themedicineprogram.com/form.html to get online application.
National Prescription Program
Another program to help defray costs of medicine or provide prescription medicine. Call (800) 762-4636 for details.
Home Energy Assistance Cooling Off Program-Human Services, Inc.
Federal program to assist low income and or disabled individuals escape the heat. The same type of program is available for winter energy needs.
It can also help in initial hook up fees. Ask your energy provider (your local electric or gas utility, or your heating oil retailer) for details.
Check with your phone company about help on phone bill for the elderly or disabled. These programs are seldom advertised and can pay up to half of your phone bill.
These services can provide help on simple home repairs. Ask your local senior citizen organization.
Many churches sponsor programs to help elderly with tasks they can not pay for or do themselves, call around.
National Eye Care Project
Free eye appointments and referrals if needed. Call (800) 222-3937 for more information. And check with your local Lion's Club for free glasses.
Meals on Wheels
This program provides meals to elderly people right to their door.
Nurse help that travels to the elderly person's home.
The most important thing: ASK!
I can't stress this enough, a simple phone call and you will be on your way. Most cities have free dental as well as health programs. Call First Call For Help in your area. The United Way can direct you as well. Their numbers should be in the phonebook.
Barbara Richardson is 37 years old and lives on 13 acres in Indiana with her husband and three children, and a dog and cat. She loves fishing, cartooning, writing, animals, cooking, bread baking, and her family, not specifically in that order. Barbara says, "I am proud to be a stay at home and a wife. I take pride as well in living within my income and not being a slave to debt."
- Keeping Them Healthy, Keeping Them Home: How to Care for Your Loved Ones at Home--What it says, a complete guide to taking care of your older loved ones at home, from medical care to emotional considerations to taking care of the caretaker (that means you).
- The Complete Eldercare Planner--A step-by-step planner for your elders' later years.
- AGENET: Many helps for the elderly and caregivers.
- Social Security Advisory Service Public Posting Board: A place to talk to others about Social Security concerns and questions.
- Social Security Handbook Online