Original Medicare (MA)
(H5378-803)

by Original Medicare - Lawrence County, MS

If you have a Medigap (Medicare Supplement Insurance) policy, your costs may be lower for some benefits. If you receive Medicaid benefits from your State, your costs may be lower for some benefits.

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Plan Rating	n/a
Premium and Other Important Information	In 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.
	If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.
	Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Doctor and Hospital Choice	You may go to any doctor specialist or hospital that accepts Medicare.

Inpatient Hospital Care	In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day
	Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.
	Lifetime reserve days can only be used once.
	"A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Inpatient Mental Health Care	In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day
	You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

Skilled Nursing Facility (SNF)	In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $144.50 per day
	100 days for each benefit period.
	"A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Home Health Care	$0 copay.

Hospice	You pay part of the cost for outpatient drugs and inpatient respite care.
	You must get care from a Medicare-certified hospice.

Doctor Office Visits	20% coinsurance

Chiropractic Services	Supplemental routine care not covered
	20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

Podiatry Services	Supplemental routine care not covered.
	20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs.

Outpatient Mental Health Care	40% coinsurance for most outpatient mental health services
	Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.
	"""Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."

Outpatient Substance Abuse Care	20% coinsurance

Outpatient Services/Surgery	20% coinsurance for the doctor's services
	Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible.
	20% coinsurance for ambulatory surgical center facility services

Ambulance Services	20% coinsurance

Emergency Care	20% coinsurance for the doctor's services
	Specified copayment for outpatient hospital facility emergency services.
	Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.
	You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.
	Not covered outside the U.S. except under limited circumstances.

Urgently Needed Care	20% coinsurance or a set copay
	NOT covered outside the U.S. except under limited circumstances.

Outpatient Rehabilitation Services	20% coinsurance

Durable Medical Equipment	20% coinsurance

Prosthetic Devices	20% coinsurance

Diabetes Programs and Supplies	20% coinsurance for diabetes self-management training
	20% coinsurance for diabetes supplies
	20% coinsurance for diabetic therapeutic shoes or inserts

Diagnostic Tests X-Rays Lab Services and Radiology Services	20% coinsurance for diagnostic tests and x-rays
	$0 copay for Medicare-covered lab services
	Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.

Cardiac and Pulmonary Rehabilitation Services	20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services
	This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.

Preventive Services and Wellness/Education Programs	No coinsurance copayment or deductible for the following:
	Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39. Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.

Kidney Disease and Conditions	20% coinsurance for renal dialysis
	20% coinsurance for kidney disease education services

Outpatient Prescription Drugs	Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

Dental Services	Preventive dental services (such as cleaning) not covered.

Hearing Services	Supplemental routine hearing exams and hearing aids not covered.
	20% coinsurance for diagnostic hearing exams.

Vision Services	20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.
	Supplemental routine eye exams and glasses not covered.
	Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
	Annual glaucoma screenings covered for people at risk.

Over-the-Counter Items	Not covered.

Transportation	Not covered.

Acupuncture	Not covered.

Point of Service	You may go to any doctor specialist or hospital that accepts Medicare.

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Medicare Terms

• Co-payment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
• Cost Plans: A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
• Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
• HMO - Health Maintenance Organization: Local HMOs are plans with defined networks of providers, which beneficiaries must use in order to receive coverage, serving specific geographic areas consisting of aggregations of counties.
• HMO SNP - Special Needs Plan: Medicare Special Needs Plans are a type of Medicare Advantage Plan (Part C) for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions). Medicare SNPs provide their members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D). Medicare SNPs were created to give certain groups of people better access to Medicare with plans designed to meet their unique needs.
• HMO with POS Option: An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
• LPPO - Local Preferred Provider Organization: Local PPOs are network based plans that serve specific geographic areas consisting of aggregations of counties, like HMOs, but with more flexibility in provider choice within the network. Beneficiaries may use providers outside the network but will pay more out of pocket cost.

See All Terms

Related Links

Medicare.gov The official U.S. Government site for Medicare
AARP American Association of Retired Persons
HHS.gov United States Department of Health & Human Services
CMS.gov Centers for Medicare & Medicaid Services
Social Security Administration The official website of the U.S. Social Security Administration

Original Medicare (MA)(H5378-803)

Original Medicare (MA)
(H5378-803)