Health Insurance for Railroad Retirement
Beneficiaries in Canada

RB-104 (10-81)

This information is from a leaflet sent to annuitants living in Canada when they become eligible for Medicare.

Please read this leaflet carefully and keep it in a safe place. It explains how the Medicare program applies to railroad retirement beneficiaries living in Canada. If you receive covered hospital services in Canada, you will need Form AA - 104 to claim benefits.

INTRODUCTION

The health insurance program under Medicare consists of two parts:

• Part A-Hospital Insurance. You are automatically enrolled for hospital insurance.
  
• Part B-Medical Insurance. Generally, medical insurance benefits are Provided only in the United States. Therefore, you must apply if you want them.

Both hospital and medical insurance benefits are described in this leaflet.

HOSPITAL INSURANCE

The Medicare program provides hospital insurance benefits for railroad retirement beneficiaries and certain members of their families who are:

• Age 65 or over; or
  
• Under age 65 and have been disabled as set forth in the Medicare law for not less than 24 months.

Persons who qualify under the above provisions are entitled to hospital insurance benefits under Medicare for covered hospital and post-hospital services furnished in Canada or the United States.

You are or soon will be covered by the hospital insurance plan. Your health insurance card shows the date your hospital insurance coverage begins.

Hospital insurance will help pay for part of the services described below:

• Inpatient Hospital Benefits- to help pay for hospital care for up to 90 days during each "benefit period" (see page 4 for the definition of "benefit period"). There is a lifetime limit of 190 days for treatment in a mental hospital.
  
  If you need more than 90 days of hospital care in any benefit period, you may draw on 60 "lifetime reserve" days. Hospital insurance will help pay the cost. Each "lifetime reserve" day used permanently reduces the total you have left.

Skilled Nursing Facility Services- to help pay for up to 100 days of extended care during a benefit period if

1. you were in the hospital for at least 3 days, and
2. your medical needs require daily skilled nursing or rehabilitation care, and
3. a doctor determines that you need extended care and orders your care, and
4. you are admitted within a limited period, generally 14 days after you leave the hospital, and
5. you are admitted for further treatment of a conditi6n for which you were treated in the hospital.

Home Health Benefits- to cover home health visits, under certain conditions, by nurses or other health workers from qualified home health agencies. Hospital insurance pays for up to 100 visits in the 1 -year period following your most recent discharge from a hospital or skilled nursing facility if

1. you were hospitalized for at least 3 days, and
2. your physician arranges for the services within 14 days after your discharge, and
3. you are treated for a condition for which you were treated in the hospital or skilled nursing facility.

Payments for services furnished in Canada are reduced by whatever is payable for those services under Canadian law. In other words, the described benefits are limited to the amount by which the regular hospital insurance benefits under Medicare exceed the amount payable under Canadian Provincial plans.

What services are covered?

Covered services in a hospital or skilled nursing facility include the cost of room and meals (including special diets) in semiprivate accommodations (2 to 4 beds), regular nursing services, and services in an intensive care unit of a hospital. They also include the cost of drugs, supplies, appliances, equipment, and any other services ordinarily furnished to inpatients of the hospital or skilled nursing facility in which you are treated.

Covered home health benefits include part-time skilled nursing care, physical therapy, or speech therapy. If you need skilled nursing care or physical or speech therapy, Medicare will also help pay for occupational therapy and for medical supplies and appliances furnished by the home health agency.

What services are not covered?

Hospital insurance is basic protection against the high cost of illness after you are 65 or while you are severely disabled, but it will not pay all of your health care bills. No payment will be made for:

• Doctor bills.

• Private duty nurses.

• Convenience items requested by you, such as a telephone or television in your room.

• Custodial care- care which is primarily to help with personal, daily needs such as bathing, eating, or dressing.

"Benefit Period''- Defined

A "benefit period" BEGINS on the first day you receive covered services as a patient in a hospital and ENDS after you have been out of a hospital or skilled nursing facility for 60 consecutive days.

You may be discharged and readmitted several times during a benefit period, but a NEW benefit period cannot begin until you have not been a patient in any hospital or skilled nursing facility for 60 consecutive days.

HOW TO CLAIM BENEFIT PAYMENTS

Complete Form AA-104 to claim benefits for covered services you received in Canada. Send the completed form to the Railroad Retirement Board along with your receipted bills for the services. If none of the charges for the services were payable under a Provincial hospital plan, you must also attach a statement signed by your doctor certifying that the services furnished were medically necessary.

if you receive services covered by Medicare hospital insurance and the services are furnished in the United States, do not file Form AA-104. Just show your health insurance card to the people at the place where you receive the services. They will handle the claim for payment.

MEDICAL INSURANCE

Except on rare occasions (emergencies occurring while traveling between Alaska and another state of the United States, or one occurring in the United States with services rendered in a nearby Canadian hospital) medical insurance does not pay for medical services furnished in Canada. These payments are limited to services in the United States, where 80% of the approved charges are paid after the annual deductible has been satisfied.

The services covered under medical insurance in the United States include:

• Physicians' and surgeons' services in the hospital, doctor's office, home, or elsewhere.
• Limited chiropractic services.
• Up to 100 home health visits under an approved plan each year with no need for prior hospitalization. This is in addition to the 100 visits provided under the hospital insurance program.

• A number of other medical and health services, such as diagnostic services, X-ray or radioactive treatments, surgical dressings and splints, casts, and rental or purchase of medical equipment.

• Drugs a doctor administers to you as part of his professional services which cannot be selfadministered.
• The full approved charges for laboratory, X-ray or other radiology services furnished by physicians while you are a bed patient in a hospital.

• Outpatient physical therapy services-whether or not you are homebound-furnished under supervision of a participating hospital, skilled nursing facility or home health agency, or an approved clinic, rehabilitation agency, or public health agency.

• All covered outpatient hospital benefits whether for diagnosis or treatment.
• Certain services by podiatrists (but not routine foot care, treatment of flat feet, or partial dislocations).
• Certain ambulance services.

SERVICES NOT COVERED UNDER MEDICAL INSURANCE

Medical insurance does not cover some services such as the cost of routine physical check-ups, drug prescriptions, eye glasses, hearing aids, and ordinary dental treatment.

WHEN YOU CAN ENROLL IN THE MEDICAL INSURANCE PROGRAM

To get medical insurance, you must sign up for it within special enrollment periods set by law. Your first enrollment period begins three months BEFORE and extends three months AFTER the month you reach age 65 or have been disabled for the prescribed period of time.

But to be sure your protection begins as soon as you are eligible, you need to sign up before the hospital insurance effective date shown on your identification card. If you do not enroll in the first three months of your enrollment period, your medical insurance coverage will be delayed from 1 to 3 months after you enroll.

If you do not sign up during your first enrollment period, you may sign up during a general enrollment period (January thru March of each year). If you wait until then to enroll, you may have to pay a higher premium for the same protection, and your coverage would not begin until the following July.

SHOULD YOU ENROLL FOR MEDICAL INSURANCE?

Since medical insurance is voluntary, you will have this coverage only if you enroll for it. In making your decision, you should consider these facts:

• If you will not be coming to the United States in the future-either to five or to receive medical services-it will not be to your advantage to enroll for medical insurance because payments generally cannot be made for services received outside the United States.
  

• If you expect to come to the United States-either to live or to receive medical care-and you want the medical insurance coverage, you should sign up now.

IF YOU DECIDE TO DROP MEDICAL INSURANCE

If you decide to drop out of the medical insurance program, you may do so at any time. Your coverage would be terminated at the end of the next calendar quarter. (You would, of course, still have the hospital insurance coverage.) If you drop out, you may reenroll, but only during a General Enrollment Period, January, February and March each year. There is no limit to the number of times you can enroll during your lifetime.

HOW DO YOU PAY FOR MEDICAL INSURANCE?

If you are receiving a railroad retirement annuity, your premium will be deducted from your annuity payments when your coverage begins. If you are not eligible for your annuity payments for one or more months, you will be informed how to pay your premiums.

The monthly premium rate is shown on the enclosed card. As required by law, the premium rate is reviewed each year to see if an adjustment is needed to meet the expenses for the year. More than two-thirds of the cost of your medical insurance is paid from general revenues of the Federal Government.

IF YOU WANT MEDICAL INSURANCE

In order to enroll for medical insurance, complete the enclosed application card and return it in the enclosed envelope.

• If you sign by mark (X) have someone who knows you sign his name and show his address in the space provided on the card.
  

• If you are receiving benefits for someone else, sign your name. For example, if the card is addressed "Bill Jones for John Smith," Bill Jones should complete and sign the card.

• If the card is addressed to an institution, it may be completed and signed by an authorized official of the institution and Ws signature should be followed by his title.

IF YOU DO NOT WANT MEDICAL INSURANCE

If you do not want medical insurance:

• Destroy the enclosed application card and envelope.
  
• Take no further action.

YOUR HEALTH INSURANCE CARD

The enclosed health insurance card shows you have hospital insurance. If you sign up for medical insurance, we will send you a new card showing you have both hospital and medical insurance.

Your health insurance card shows your personal claim number and is for your use only. When a husband and wife are both signed up, each receives a separate card and claim number.

If you lose your card, let us know right away. We will send you a new one.

ANY QUESTIONS?

This leaflet cannot give all the details of your coverage under Medicare. If you have questions which are not answered by the leaflet, you may write to:

U. S. Railroad Retirement Board
844 Rush Street
Chicago, Illinois 60611
U.S.A.