About Medicare Benefits and Programs

Home health care includes part-time skilled nursing care, physical therapy, speech-language therapy, home health aide services, durable medical equipment, supplies and other services.

Medicare provides for full payment of intermittent part-time skilled care from registered nurses, therapists and home health aides from a Medicare-approved home health agency. Intermittent part-time care is generally defined as care for two to three days a week up to four or six weeks. In exceptional cases, longer care may be provided. In order to be eligible, a beneficiary must meet all of the following criteria:

• Be under the care of a doctor
• Need care for a specific illness
• Be homebound
• Need skilled services
• Need services on a part-time or occasional basis

If you require skilled services (nursing, physical therapy or speech therapy), you may also receive occupational therapy, social work services and home health aide services if your physician determines you need them. Prior hospitalization is not necessary to receive home health services under Medicare. You pay nothing toward home health services and 20 percent of the Medicare-approved amount for durable medical equipment.

Medicare pays for unlimited hospice care for terminally ill patients in a Medicare-approved hospice program through four benefit periods. There are no deductibles or copayments, except for covered prescription drugs and inpatient respite care. Individuals must choose hospice care. Beneficiaries pay a co-payment of up to five dollars for outpatient prescription drugs and five percent of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver so the usual caregiver can rest).

Inpatient hospital care includes a semiprivate room, meals, general nursing, and other hospital services and supplies. It does not include private duty nursing, a television or telephone in your room, or a private room, unless medically necessary. Inpatient mental health care coverage in a psychiatric facility is limited to 190 days in a lifetime.

Benefits are paid on the basis of "benefit periods." A benefit period begins the first day you are hospitalized and ends when you have been out of a hospital or skilled nursing facility for 60 consecutive days. If you enter a hospital again after 60 days, a new benefit period begins.

In 2024, a Medicare beneficiary is responsible for a deductible of $1,632 for the first day of each benefit period, after which Medicare pays for up to 60 days of full hospital care. For days 61 to 90, the beneficiary is responsible for $408 per day (copayment). In addition, a beneficiary has 60 lifetime reserve days and would be responsible for a copayment of $816 per day for days 91 to 150. There is no Medicare coverage for days 150 to 365.

A semi-private room, meals, skilled nursing, rehabilitative services, and other services and supplies are provided after a hospital stay of at least three consecutive days if ordered by the doctor. Medicare covers 100 days of skilled nursing or rehabilitative care in a Skilled Nursing Facility (SNF), provided the SNF is approved by Medicare and your treatment is connected with the illness that caused you to be hospitalized. You must need skilled nursing care or skilled rehabilitative care on a daily basis. Medicare pays days 1 to 20 in full; the beneficiary is responsible for a $204 per day copayment for days 21 to 100. No custodial or intermediate nursing home care is provided.

As of January 1, 2021, the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Program (DMEPOS) has been changed. The only pieces of durable medical equipment (DME) that must be purchased in Baltimore County from a Medicare Contract Supplier are over-the-counter back and knee braces. 

The goal of this program is to save Medicare and beneficiaries money while enhancing service. Potential suppliers submitted bids. The winning suppliers are called Medicare Contract Suppliers. If you live in or are visiting a CBA, you must purchase the above items from a Medicare Contract Supplier who serves the area if you would like Medicare to pay for it. The beneficiary would still be responsible for the Part B deductible and the 20 percent co-insurance. To determine if a ZIP code is in a CBA or to locate the Medicare Contract Suppliers for the CBA, call your local State Health Insurance Assistance Program (SHIP) at 410-887-2059 or call Medicare at 1-800-MEDICARE (1-800-633-4227), or visit the Medicare website.

DMEPOS not listed above may be purchased from any Medicare-approved supplier. Always ask the supplier if they accept Medicare "assignment" to ensure that you will not have to pay more than a 20 percent co-insurance.

Medicare pays the full-approved charge for flu shots and pneumococcal vaccine, and its administration. Neither the annual Part B deductible nor the 20 percent copayment apply to these services. Medicare covers certain oral anti-cancer drugs, subject to the Part B premium and 20 percent copayment rules. Medicare helps pay for Hepatitis B vaccine and its administration, furnished to beneficiaries considered to be at high or intermediate risk of contracting the disease. Medicare also pays for immunosuppressive drugs, post transplant, if the transplant was performed in a Medicare-approved facility and the patient is enrolled in Medicare Part A at the time of the transplant.

All diabetic testing supplies that are delivered to the home need to be purchased from National Mail-Order Contract Suppliers for Medicare to pay for the items. This change decreases the amount Medicare and beneficiaries pay for these items while ensuring the quality of the program. You may elect to purchase your supplies at a local store (pharmacy or storefront supplier), but be sure they are Medicare-approved suppliers who accept assignment. Local stores that do not accept assignment may charge more than the 20 percent co-insurance.

Medicare pays 100 percent coverage for:

• Annual preventative wellness visit
• "Welcome to Medicare" visit during the first 12 months on Medicare Part B
• A depression screening done in a primary care setting on an annual basis
• One EKG screening, if referred at the "Welcome to Medicare" visit
• One abdominal aortic aneurysm screening if referred during the "Welcome to Medicare" visit
• HIV screening on an annual basis, unless pregnant
• An obesity screening done once a year by primary care providers and for face-to-face counseling (call for details)
• Smoking cessation by a qualified professional
• An annual alcohol misuse screening and up to four face-to-face counseling sessions with a qualified primary doctor or provider
• Blood test screenings for cholesterol, lipid and triglycerides levels once every five years
• Diabetic screenings, up to one to two tests per year depending on your risk level
• Flu vaccinations once a year, a pneumonia vaccination once in your lifetime and a hepatitis shot for high-risk individuals
• Bone mass measurement tests that detect bone loss and qualify to determine the likelihood of the person developing osteoporosis (for individuals at high risk)
• One pap smear screening and related medically necessary physician services, including a physician's interpretation of the results of the tests every two years, or more frequently for women at high risk of developing cervical or vaginal cancers

Medicare will pay 80 percent coverage for:

• Diabetes self-management training with a written order from a provider
• Diabetic supplies—blood sugar test strips, testing monitors, lancets and test solution
• Glaucoma screenings once every 12 months for individuals at risk for glaucoma, including people with diabetes or a family history of glaucoma

Other coverage provided by Medicare:

• Medicare may cover 100 percent for medical nutritional therapy if you have diabetes or kidney disease, and your doctor refers you.
• Medicare will provide coverage for colon cancer screening tests; there are a variety of tests covered depending upon a person's risk of developing colon cancer.
• Beneficiaries 40 years of age and older are entitled to one screening mammogram every year. Medicare will pay a maximum of 100 percent of the approved charge; the Medicare Part B deductible will not apply. Beneficiaries must receive their mammography services at a Medicare-approved mammography site.
• Medicare will cover prostate cancer screening (digital rectal exams and prostate specific antigen tests) for men age 50 and older—80 percent coverage for the exam; no co-insurance or deductible for the PSA test.
• Medicare covers the costs of blood glucose monitors and most of the cost of test strips for people with diabetes (both insulin and non-insulin dependent), and will provide coverage for educational and training services furnished to an individual with diabetes by a qualified provider at the direction of the beneficiary's physician.

• Physician (Inpatient and Outpatient)
• Outpatient
• Outpatient Physical
• Speech and Occupational Therapy
• Durable Medical Equipment and Supplies

A Medicare beneficiary pays a $240 annual deductible and a 20 percent copayment for Medicare-approved charges and services. Medicare pays 80 percent of its approved charge. A beneficiary pays all costs above Medicare-approved charges ("excess charge"). Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge Medicare beneficiaries for covered services. The limiting charge is 15 percent of the fee schedule amount for non-participating physicians.

Note: Certain Medicare-covered services such as mental health services, physical and occupational therapy, and certain services rendered by special practitioners have special payment rules.

The QMB program, also known as "quimby," will pay the Part A ($505 in 2024 if you did not work and pay FICA tax for 10 years in the U.S.) and Part B premiums ($174.70 in 2024), deductibles and coinsurance payments of the Medicare Program for older and individuals with disabilities who are financially eligible.

QMB-eligible beneficiaries must go to medical care providers who accept Medicare and QMB. In addition to the income and assets stated, an individual or couple may have a house (in which they live) and a car.

CURRENT ELIGIBILITY GUIDELINES

ANNUAL AND MONTHLY GROSS INCOME

• Single: $15,300 per year or $1,275 per month
• Couple: $20,688 per year or $1,724 per month

Note: Wages for QMB: Deduct $65 from gross wages for each month worked and divide the sum by two. This figure is the amount of wages to be used when determining income eligibility.

ASSETS

• Single: $9,430
• Couple: $14,130

Assets do not include $1,500 per person burial allowance (must be in a dedicated account).

WHAT YOU NEED TO DO

For an application, call Baltimore County SHIP at 410-887-2059 or the Department of Social Services.

AFTER APPLYING

Once the application has been processed, the Department of Social Services sends a letter to tell client if they are eligible. If eligible, a gray and white paper card will be received.

All QMB beneficiaries receive a Case Information Form (CIF) each year to be reviewed and returned so eligibility for continued QMB benefits can be determined.

If the form is not returned by the due date, your benefits will end.

The SLMB program, also known as "slimby," will pay the Medicare Part B premium ($174.70 per month in 2024) for people whose income is slightly more than the QMB criteria.

In addition to the income and assets stated, an individual or couple may have a house (in which they live) and a car. 

CURRENT ELIGIBILITY GUIDELINES

ANNUAL AND MONTHLY GROSS INCOME

• Single: $20,580 per year or $1,715 per month
• Couple: $27,840 per year or $2,320 per month

Note: Wages for QMB: Deduct $65 from gross wages for each month worked and divide the sum by two. This figure is the amount of wages to be used when determining income eligibility.

ASSETS

• Single: $9,430
• Couple: $14,130

Assets do not include $1,500 per person burial allowance (must be in a dedicated account).

WHAT YOU NEED TO DO

For an application, call Baltimore County SHIP at 410-887-2059 or the Department of Social Services.

AFTER APPLYING

Once the application has been processed, the Department of Social Services sends a letter to tell the client if they are eligible. No card will be received.

All SLMB beneficiaries receive a Case Information Form (CIF) each year to be reviewed and returned so eligibility for continued SLMB benefits can be determined.

If the form is not returned by the due date, your benefits will end.

The Maryland Senior Prescription Drug Assistance Program (MD SPDAP) will pay up to $75 each month toward the Medicare Prescription Drug plan premium.

GROSS INCOME

• Single: Under $43,740
• Couple: Under $59,160

Assets are not counted.

ASSISTANCE

Up to $75 toward the monthly premium

WHAT YOU NEED TO DO

Apply through MD SPDAP: Call 1-800-551-5995 or visit the Senior Prescription Drug Assistance Program website.

Low Income Subsidy (LIS) Medicare Beneficiaries who qualify based on low income and limited assets will receive a subsidy to pay for Medicare Part D premiums, copayments, deductibles and coverage gap (donut hole).

FULL EXTRA HELP

• GROSS INCOME

  • Single: Under $22,110 or $1,882 per month
  • Couple: Under $29,820 or $2,555 per month

• ASSETS

  • Single: Under $17,220
  • Couple: Under $34,360
  • When calculating assets, include $1,500 per person burial allowance.

• ASSISTANCE

  • Monthly premium
  • No deductible
  • $4.50 generic drug
  • $11.20 brand name drug

• WHAT YOU NEED TO DO

  • Apply through Social Security: Call 1-800-772-1213 or visit the Social Security Administration website.
  • May also be eligible for QMB or SLMB. For an application, call Baltimore County SHIP or the Department of Social Services.

FULL BENEFIT DUAL EXTRA HELP

• GROSS INCOME AND ASSETS

  • Full Medical Assistance Eligible (red and white card)

• ASSISTANCE

  • No premium
  • No deductible
  • $1.55 generic drug
  • $4.60 brand name drug

• WHAT YOU NEED TO DO

  • Automatically enrolled in Extra Help. Do not apply through Social Security.
  • Medicare premiums, deductibles and copays will be paid through the Department of Social Services.

DEFINITIONS

• Assets: IRAs, CDs, Savings, Checking, Annuities, etc. Primary house and car not counted as assets or resources.
• Income: Gross pension, social security, alimony, worker's compensation, etc.
• Couple: Defined as married and living together.
• Wages: Deduct $65 from gross wages for each month worked and divide the sum by two. This figure is the amount of wages to be used when determining eligibility.