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We want you to have the best possible healthcare experience. Our dedicated Customer Care Team can offer personal attention, special services and expert guidance.
Call our Customer Care Team below and one of our friendly, knowledgeable, bilingual counselors can answer your questions and help you find a plan that fits your needs.
Call (866) 955-4289

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Our Medicare Partners

Medicare Fast Facts

What you need to know.

Making decisions about health insurance can seem overwhelming at times. There is so much to consider, such as coverage, costs and access to care. EHS Medicare 101 can help you understand the basics and begin to determine what type of health plan is right for you.

What is Medicare and who is eligible?

Traditional Medicare is one of the largest national health insurance programs in the world. In 1965, the Social Security Act established Medicare. It is administered by the federal government through the Centers for Medicare and Medicaid Services (CMS).
Currently, traditional Medicare provides coverage to approximately 40 million Americans. Medicare is the national health insurance program for:
U.S. citizens or permanent residents of the United States; People age 65 or older; Some people under age 65 with disabilities; People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant; and People who have worked for at least 10 years of 40 quarters in Medicare-covered employment or whose spouse has worked for at least 10 years of 40 quarters in Medicare-covered employment.
Traditional Medicare is divided into two parts:
Part A — Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home healthcare. If you meet the conditions mentioned above, there will be no premium for your Medicare Part A entitlement.
Part B — Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home healthcare. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare Part B premium.

What is covered by Medicare?

Medicare Part A Helps Cover Your:
Hospital Stays — Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental healthcare. This does not include private-duty nursing, or a television or telephone in your room. It also does not include a private room, unless medically necessary. Read Medicare and Your Mental Health Benefits for more information on inpatient mental health benefits.
Skilled Nursing Facility Care — Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day hospital stay). Read Medicare Coverage of Skilled Nursing Facility Care for more information.
Home Health Care — Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Please visit the Home Health Compare section of our website for more information.
Hospice Care — Medical and support services from a Medicare-approved hospice for people with a terminal illness, drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in your home. However, short-term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed. Read Medicare Hospice Benefits for more information.
Blood — Pints of blood you get at a hospital or skilled nursing facility during a covered stay.
Medicare Part B Helps Cover Your:
Medical and Other Services — Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers). Also covers second surgical opinions, outpatient mental healthcare, outpatient physical and occupational therapy, including speech-language therapy. Read Medicare and Your Mental Health Benefits and Getting a Second Opinion Before Surgery for more information.
Clinical Laboratory Services — Blood tests, urinalysis and more.
Home Health Care — Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) and medical supplies, and other services. Please visit the Home Health Compare section of our website for more information.
Outpatient Hospital Services — Hospital services and supplies received as an outpatient as part of a doctor’s care. Read Your Guide to the Outpatient Prospective Payment System for more information.
Blood — Pints of blood you get as an outpatient or as part of a Part B covered service.
Medicare Also Helps Cover:
  • Ambulance services (when other transportation would endanger your health).
  • Artificial eyes.
  • Artificial limbs that are prosthetic devices, and their replacement parts.
  • Braces — arm, leg, back and neck.
  • Chiropractic services (limited) for manipulation of the spine to correct a subluxation.
  • Emergency care.
  • Eyeglasses — one pair of standard frames after cataract surgery with an intraocular lens.
  • Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare).
  • Kidney dialysis. Read Medicare Coverage of Kidney Dialysis and Kidney Transplant Services for more information.
  • Macular degeneration of the eye (“wet” age-related) treatment, using ocular photodynamic therapy with verteporfin.
  • Medical nutrition therapy services for people with diabetes or kidney disease with a doctor’s referral.
  • Medical supplies — items such as ostomy bags, surgical dressings, splints, casts and some diabetic supplies.
  • Outpatient prescription drugs (very limited). For example, some oral drugs for cancer.
  • Preventive services. Read Women with Medicare — Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam for more information.
  • Prosthetic devices, including breast prosthesis after mastectomy.
  • Second opinion by a doctor (in some cases). Read Getting a Second Opinion Before Surgery for more information.
  • Services of practitioners such as clinical social workers, physician assistants and nurse practitioners.
  • Telemedicine services in some rural areas.
  • Therapeutic shoes for people with diabetes (in some cases).
  • Transplants — heart, lung, kidney, pancreas, intestine, bone marrow, cornea and liver (under certain conditions and when performed at approved facilities).
  • X-rays, MRIs, CAT scans, EKGs and some other diagnostic tests.

Who do I contact for more information?

You can contact the EHS Medicare Member Assistant Line at (866) 430-4288. Or, contact your health plan below:

Health Plan Contacts

Additional information and resources are available at:
Medicare.gov (www.medicare.gov)
Phone: (800) 633-4227
Centers for Medicare and Medicaid Services (www.cms.gov)
Phone: (800) 633-4227
Social Security (www.ssa.gov)
Phone: (800) 772-1213

How do I get coverage for services not covered under Medicare Part A and Part B?

Medicare Part C — The Medicare Advantage Program
Medicare Part C, also known as the Medicare Advantage program, allows you to choose a health plan offered by a private insurance company that is approved by Medicare. Medicare Advantage plans include:
  • Managed Care Organizations (such as a PPO or HMO)
  • Private Fee-for-Service (PFFS) Plans
Medicare Advantage plans receive payments from Medicare to provide you with the benefits covered by Medicare, including Part A (hospital) and Part B (physician and outpatient services). Most Medicare Advantage plans include Part D coverage (prescription drug benefits) and many offer extra coverage, such as vision and hearing care, dental services, and health and wellness programs.
In addition to your Part B monthly premium, your Medical Advantage plan can also charge an additional monthly premium and copayments for some services.
Medicare Part D
Medicare Part D, an outpatient prescription drug benefit, is offered to everyone with Medicare. To get Part D drug coverage, you have to join a plan run by a private insurance company that has been approved by Medicare or enroll in a Medicare Advantage plan that includes drug coverage.
Part D prescription plans are offered on a state-by-state basis and most states have 40 or more plans available. Although all these plans must offer at least a “standard” drug benefit determined by Medicare, they may provide additional benefits.
Choosing a Part D plan can sometimes be challenging due to a wide range of out-of-pocket expenses and the extra benefits provided. Drug plans with higher monthly premiums usually have a lower, or no annual deductible and cover some medications in the donut hole — a gap in coverage when your plan stops paying for your prescriptions and you are responsible for 100% of the costs.
With the passage of the Patient Protection and Affordable Care Act signed into law on March 23, 2010 by President Obama, seniors who are enrolled in a Part D plan will see a reduction in the amount they must pay for their prescription drugs when they reach the donut hole. By 2020, the donut hole will essentially be “closed” and rather than paying 100% of the costs, your responsibility will be 25% of the costs.

Does Medicare cover everything?

No. There are financial gaps in Medicare coverage. Here is a brief summary of some of the out-of-pocket medical expenses you can expect to pay with Medicare coverage alone:
Traditional Medicare Part A financial gaps:
$1,100 deductible, for the first 60 days of a hospital stay (semi-private rooms only; TVs and telephones not included);
$275 per day copayment for days 61-90 of your stay;
$550 per day copayment for each lifetime reserve day used;
Non-emergency care in a hospital that does not participate in Medicare; and care received outside the United States and its territories, except under limited circumstances in Canada and Mexico.
Medicare Part B financial gaps:
$135 annual deductible;
Generally, 20% co-insurance and permissible charges in excess of Medicare-approved amount;
All charges for most prescription drugs and most immunizations;
Generally, 20% of Medicare-approved amount for routine physicals and other screening services, except for periodic mammograms and pap smears;
All charges for routine eye examinations or eyeglasses;
All charges for hearing aids or routine hearing loss examinations;
All charges for dental care and dentures (with a few exceptions); and
All charges for acupuncture and chiropractic services
* Rates based on Medicare 2010.

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