1. What is Medicare?
2. How do I get Medicare?
3. Am I eligible for Medicare if I am 65 and have never
worked but my spouse has?
4. What kind of health insurance is Medicare?
5. What does Part A Medicare pay for?
6. What do I pay for Part A Medicare?
7. What services will Part B Medicare cover?
8. What are services that Part B Medicare will not cover?
9. How do I pay for my Part B Medicare benefits?
10. How does Medicare work?
11. Who are the Medicare Carriers for New York State?
12. What is durable medical equipment and is it covered
by Part B Medicare?
13. Do I ever have to submit my own claim to Medicare?
14. What is the difference between Participating and
Non-participating providers?
15. Who protects my rights as a Medicare beneficiary?
16. Where can I get more information about health
insurance?
17. Where can I get a list of participating providers in
Queens County?
18. Since GHI is the Medicare Carrier for Queens County
and I live in Queens County, does that mean that GHI will always get my Medicare
claims?
19. How can I contact the Health Care Financing
Administration?
20. Will Medicare automatically cross a claim over to my
21. How long will it take Medicare to pay my claim?
22. Will Medicare always be my primary insurance?
23. What is a Medigap insurance plan?
1. What is Medicare?
Medicare is a national health insurance program for people 65 years of age and older, certain younger disabled people and people with end stage renal disease.
Back to Top
2. How do I get Medicare?
To be eligible for Medicare an individual must be a citizen or permanent resident of the United States who has worked, and contributed to Social Security, for at least ten years and be at least 65 years of age. People under 65 are entitled to Medicare if they have been receiving Social Security benefits for 24 months or have end stage renal disease. If you have any questions about Medicare eligibility, you should contact your local Social Security office.
Back to Top
3. Am I eligible for Medicare if I am 65 and have never
worked but my spouse has?
Back to Top
4. What kind of health insurance is Medicare?
Medicare has both hospital insurance and medical insurance that pays for medically necessary services performed in the United States. Medicare does not pay for medical services abroad. The hospital insurance is called Part A Medicare. The medical insurance is called Part B Medicare.
Back to Top
5. What does Part A Medicare pay for?
Part A Medicare pays for the cost of a medically necessary stay in an inpatient hospital, skilled nursing facility, hospice and home health care. Part A Medicare pays for the following : - Semiprivate room & board
- General nursing
- Other hospital services & supplies
Back to Top
6. What do I pay for Part A Medicare?
Part A Medicare pays for services in units known as Benefit Periods. A Benefit Period begins the day you are admitted to the hospital and ends after you have been out of the hospital for 60 consecutive days. For the cost of a hospital stay up to 151 days, please refer to the chart below: | Day 1 - Day 60 | Day 61 - Day 90 | Day 91 - Day 150 | Day 151 And on | | | | | | | | What you pay | The Medicare Part A Deductible of $760.00 whic covers the first 60 days of any hospital stay | $190.00/day | $380/day | You pay all costs | * Most people do not pay premiums for Part A Medicare . People only pay premiums for Part A Medicare if they have worked less than ten years. *
Back to Top
7. What services will Part B Medicare cover?
Part B Medicare pays for the cost of medically necessary doctor's services and other medical services and supplies. The following is a partial list of services that Part B Medicare covers : - Outpatient hospital services
- X-rays and laboratory tests
- Ambulance transportation
- Breast prostheses following a mastectomy
- Flu, pneumonia and hepatitis shots
- Pap smears for detection of cervical cancer
- Mammograms to screen for breast cancer
- Outpatient mental health services
- Artificial limbs and eyes
- Durable medical equipment * Medicare will only pay for a limited amount of physical therapy & occupational therapy per year. Medicare will also pay for a very limited range of Chiropractic and Podiatry services. Medicare pays for ambulance services however this benefit is strictly limited. *
Back to Top
8. What are services that Part B Medicare will not cover?
Back to Top
9. How do I pay for my Part B Medicare benefits?
An individual pays for their Part B Medicare benefits in three ways: Premiums, deductibles and coinsurance. Please see the chart below for a detailed description. | How much do I pay | When do I pay | | Deductible | $100.00 | For the first $100.00 worth of services in any calendar year. | | | | | Premiums | $43.80 | Monthly. The premiums are taken directly from your social security checks. | | | | | Coinsurance | 20% of whatever Mecicare allows for a given service | Each time you go to a provider, Medicare allows a certain amount for the procedure which you are notified and expected to pay 20% of the allowance. | | | |
Back to Top
10. How does Medicare work?
Medicare is funded and overseen by the Health Care Financing Administration, HCFA, but is administered by private insurance companies that have contracts with HCFA to administer the Medicare program for a distinct geographic area. The private insurance companies that are contracted by HCFA are called Carriers. What do Carriers do? A Carrier's responsibilities include but are not limited to the following: - Answering inquiries from beneficiaries & providers
- Monitoring for fraud and abuse
- Processing Medicare claims and determining the appropriateness of payment
Back to Top
11. Who are the Medicare Carriers for New York State?
For Queens County- GHI. (800)632-5572
TTY Line (646)458-6794 For Bronx, Columbia, Delaware, Dutchess, Greene, Kings, Nassau, New York, Orange, Putnam, Richmond, Rockland, Suffolk, Sullivan, Ulster & Westchester Counties- Empire Blue Cross And Blue Shield . (800) 442-8430 For the rest of the state- BC/BS of Western New York. (800) 252-6550 For claims involving durable medical equipment- Blue Cross/Blue Shield of Western New York. (800) 842-2052
Back to Top
12. What is durable medical equipment and is it covered
by Part B Medicare?
Part B Medicare pays for durable medical equipment as long as it is medically necessary. Examples of durable medical equipment are listed below: - Wheelchairs
- Canes & walkers
- Oxygen tanks
- Hospital beds
Back to Top
13. Do I ever have to submit my own claim to Medicare?
Back to Top
14. What is the difference between Participating and
Non-participating providers?
There are only two kinds of providers in the Medicare program: participating & non participating. A participating provider has signed an agreement where he/she agrees to accept whatever Medicare approves for a service as payment in full. For example, if Medicare approves payment to the provider of $100.00; Medicare would pay 80%, 80 dollars, and it is the beneficiary's responsibility to pay the balance between what Medicare approved and paid in this case 20 dollars or 20%. With a participating provider the beneficiary's responsibility will always be 20% of whatever Medicare approves A non participating provider has not signed an agreement with Medicare and can charge a Medicare beneficiary up to115% above what Medicare would normally allow for a given service. So if Medicare would normally allow $100.00 for a given service a provider can charge $115.00. Medicare will pay its 80% based on what it would normally allow. In this case it would be $80.00. The beneficiary would be responsible for the difference between $80.00 and $115.00 which would be $35.00. * New York State Medicare beneficiaries please note: New York State law limits physicians bills to 105 % of the Medicare approved amount for most services. If you have questions, call (212) 869-3850 in NYC or (800) 333-4114 in upstate. *
Back to Top
15. Who protects my rights as a Medicare beneficiary?
The Peer Review Organization. The Peer Review Organization , PRO, is funded by the Health Care Financing Administration to protect the rights of Medicare beneficiaries when they are in a hospital, hospice, skilled nursing facility and health maintenance organization. The PRO seeks to ensure that Medicare beneficiaries receive a certain standard of quality of care and any complaints about the quality of care a Medicare beneficiary receives should be forwarded to them. The Peer Review Organization for New York State is: The Island Peer Review Organization
1979 Marcus Avenue
Lake Success, NY 11042-1002
(516)326-7767
Back to Top
16. Where can I get more information about health
insurance?
There is an organization called HIICAP. HIICAP is an acronym that stands for Health Insurance Information Counseling Assistance Program. It is a program run by the New York City Department For the Aging that provides health insurance information to seniors. They have information on Health Maintenance Organizations and Medicare Supplemental Insurance. They have offices in all the boroughs where you can meet with a counselor. The telephone number for the New York City main HIICAP office is (212) 869-3850. 
Back to Top
17. Where can I get a list of participating providers in
Queens County?
A list of participating providers in Queens County can be downloaded from our website. If you need further assistance, please feel free to contact our Community Relations Department at (800) 632-5572
Back to Top
18. Since GHI is the Medicare Carrier for Queens County
and I live in Queens County, does that mean that GHI will always get my Medicare
claims?
No. Which Medicare Carrier gets the claim is determined by where the service is rendered. For example, if you live in Queens and see a doctor in Queens then GHI will get the claim but if you live in Queens and see a provider in Manhattan then Empire Blue Cross & Blue Shield will process the claim. For a complete list of Medicare carriers refer to your Medicare Handbook.
Back to Top
19. How can I contact the Health Care Financing
Administration?
Back to Top
20. Will Medicare automatically cross a claim over to my
Back to Top
21. How long will it take Medicare to pay my claim?
That depends on whether your provider submits his/her claims electronically or on paper. If the provider submits on paper and the claim is payable then the check will be released 27 days after the carrier received it. If your provider submits his/her claims electronically then the check will be released on the 13th day following the carrier's receipt of the claim.
Back to Top
22. Will Medicare always be my primary insurance?
Yes, unless : 1) You were involved in a car accident. In which case the liability or no fault insurance will pay first and Medicare will pay secondary.
2) You suffer from Black Lung Disease.
3) You or your spouse work and you have health insurance through your employer. * Medicare doesn't pay for services received in Veteran's Administration facilities *
Back to Top
23. What is a Medigap insurance plan?
A Medigap insurance plan is a health insurance plan sold by a private insurance company which covers the gaps in Medicare's coverage. For example a Medigap plan may offer coverage for eyeglasses and routine prescriptions for which Medicare does not offer coverage .
Back to Top |
