THE MEDICARE HANDBOOK
INCLUDING INFORMATION FOR BENEFICIARIES ON:
* MEDICARE BENEFITS
* PARTICIPATING PHYSICIANS AND SUPPLIERS
* HEALTH INSURANCE TO SUPPLEMENT MEDICARE
* LIMITS TO MEDICARE COVERAGE
ABOUT THIS HANDBOOK
Medicare pays for many of your health care expenses, but
it does not cover all of them. It is important for you to know
what Medicare does and does not pay for. This Handbook will
help you understand how the Medicare program works and what
your benefits are. You can use the alphabetical index at the
back of the book to find information on specific subjects. This
Handbook is also available in Spanish. (See inside back cover
for how to order.)
Don't Miss
* The Assignment Method of Payment
Many doctors and suppliers have agreed to be part of
Medicare's participating physician and supplier program. They
accept assignment on all Medicare claims. If you get your
medical services from one of these participating doctors or
suppliers, you can often save money. See page 28 for more
information about the assignment method of payment, and what
you can do to find a participating doctor or supplier.
* Your Appeal Rights
Pages 35 and 36 explain how to appeal when Medicare does
not pay your Part A or Part B claims.
* If You Need Financial Assistance to Pay for Health Care
Sometimes you can get help paying for Medicare. Look on
pages 2 and 3 for more information.
* New primary and preventive services
Medicare now has a Federally Qualified Health Center
benefit. Look on page 24.
* New Information About Insurance to Supplement Medicare
Some people want to have insurance to pay medical bills
Medicare doesn't cover. See pages 8 and 9 to find out about
Medicare supplement "Medigap" insurance, including a new open
enrollment period.
* New Benefits
Recently added Medicare Part B benefits for cancer
screening--mammograms and Pap smears--are described on page 25.
* Who Pays First?
Medicare is not always the insurer that pays first
on claims. For example, some people are employed, or their
spouse is employed, and the employer health insurance pays
first. For more about who pays first, see pages 10 and 11.
* Where to Call or Write
Look on the inside front cover to find where to call or
write to ask questions about Medicare.
This handbook is meant to explain the Medicare program,
but is not a legal document. The official Medicare program
provisions are contained in the relevant laws, regulations and
Rulings.
Save this handbook for reference. It is revised each year
and is available from Social Security, but you will not
automatically get a handbook in the mail unless there are major
changes in the Medicare program.
Contents
What is Medicare?
The Two Parts of Medicare
Who Can Get Medicare Hospital Insurance
Who Can Get Medicare Medical Insurance (Part B)?
Buying Medicare Part A and Part B
Enrollment in Medicare
Your Medicare Card
Assistance for Low-Income Beneficiaries
Intermediaries and Carriers
Peer Review Organizations
Your Right to Decide About Your Medical Care
Fraud and Abuse
Your Rights Under the Privacy Act
Medicare Coordinated Care Plans
What Are Coordinated Care Plans
Who Can Enroll in Coordinated Care Plans?
Joining a Coordinated Care Plan
Ending Enrollment in a Coordinated Care Plan
If You Have Problems
Medicare and Other Insurance
Buying Health Insurance to Supplement Medicare
When Other Insurance Pays Before Medicare
What Medicare Does Not Pay For
Custodial Care
Care Not Reasonable and Necessary Under Medicare Program
Standards
Services Medicare Does Not Pay For
Limitation of Liability
Medicare Hospital Insurance (Part A)
What Medicare Part A Includes
How Medicare Pays for Part A Services
When You Are a Hospital Inpatient
Skilled Nursing Facility Care
Home Health Care
Hospice Care
Medicare Medical Insurance (Part B)
What Medicare Part B Includes
Deductible and Coinsurance Amounts Under Part B
Doctors' Services Covered by Medicare Part B
Second Opinion Before Surgery
Services of Special Practitioners
Outpatient Hospital Services
Other Services and Supplies Covered by Medicare
Drugs and Biologicals
Medicare Payments for Outpatient Treatment of Mental
Illness
Medicare Medical Insurance (Part B) Payments
The Assignment Payment Method
Participating Doctors and Suppliers
When Your Doctor Does Not Accept Assignment
Participating Providers
Medicare Approved Amounts
Submitting Part B Claims
Getting the Part of Medicare You Do Not Have
Getting Medicare Medical Insurance (Part B)
Getting Medicare Hospital Insurance (Part A)
Special Enrollment Period
Events That Can Change Your Medicare Protection
When Protection Ends for People 65 and Older
When Protection Ends for the Disabled
When Protection Ends for Those With Permanent Kidney
Failure
How to Appeal Medicare Decisions
Appealing Decisions Made by Providers of Part A Services
Appealing Decisions Made by Peer Review Organizations
(PROs)
Appealing Decisions of Intermediaries on Part A Claims
Appealing Decisions Made by Carriers on Part B Claims
Appealing Decisions Made by Health Maintenance
Organizations (HMOs)
For More Information
Appendices
Charts: Medicare Covered Services
Medicare Carriers
Medicare Peer Review Organizations (PROs)
Index
What is Medicare?
The Medicare program is a federal health insurance program
for people 65 or older and certain disabled people. It is run
by the Health Care Financing Administration of the U.S.
Department of Health and Human Services. Social Security
Administration offices across the country take applications for
Medicare and provide general information about the program.
The Two Parts of Medicare
There are two parts to the Medicare program. Hospital
Insurance (Part A) helps pay for inpatient hospital care,
inpatient care in a skilled nursing facility, home health care
and hospice care. Medical Insurance (Part B) helps pay for
doctors' services, outpatient hospital services, durable
medical equipment, and a number of other medical services and
supplies that are not covered by the Hospital Insurance part of
Medicare. Throughout this handbook, Medicare Hospital Insurance
is called Part A and Medicare Medical Insurance is called
Part B.
Part A has deductibles and coinsurance, but most people do
not have to pay premiums for Part A (see page 33). Part B has
premiums, deductibles, and coinsurance amounts that you must
pay yourself or through coverage by another insurance plan.
Premium, deductible and coinsurance amounts are set each year
based on formulas established by law. New payment amounts begin
each January 1. When amounts increase, you will be notified.
For 1993 deductible, premium and coinsurance amounts, see the
charts on pages 37 and 38.
Who Can Get Medicare Hospital Insurance (Part A)?
Generally, people age 65 and older can get premium-free
Medicare Part A benefits, based on their own or their spouses'
employment. (Premium-free means there are no premium payments.
Most people do not pay premiums for Medicare Part A.) You can
get premium-free Medicare Part A if you are 65 or older and any
of these three statements is true:
* You receive benefits under the Social Security or Railroad
Retirement system.
* You could receive benefits under Social Security or the
Railroad Retirement system but have not filed for them.
* You or your spouse had Medicare-covered government
employment.
If you are under 65, you can get premium-free Medicare Part
A benefits if you have been a disabled beneficiary under Social
Security or the Railroad Retirement Board for more than 24
months.
Certain government employees and certain members of their
families can also get Medicare when they are disabled for more
than 29 months. They should apply at the Social Security
Administration office as soon as they become disabled.
Or, you may be able to get premium-free Medicare Part A
benefits if you receive continuing dialysis for permanent
kidney failure or if you have had a kidney transplant. (People
who can get Medicare because of kidney disease may get a copy
of Medicare Coverage of Kidney Dialysis and Kidney Transplant
Services from the Consumer Information Center. See inside back
cover for how to order.)
Check with Social Security to see if you have worked long
enough under Social Security, Railroad Retirement, as a
government employee, or a combination of these systems to be
able to get Medicare Part A benefits. Generally, if either you
or your spouse worked for 10 years, you will be able to get
premium-free Medicare Part A benefits.
Who Can Get Medicare Medical Insurance (Part B)?
Any person who can get premium-free Medicare Part A
benefits based on work as described above can enroll for Part
B, pay the monthly Part B premiums (in 1993, $36.60 for most
beneficiaries), and get Part B benefits. In addition, most
United States residents age 65 or over can enroll in Part B.
Buying Medicare Part A and Part B
If you or your spouse do not have enough work credits to
be able to get Medicare Part A benefits and you are 65 or over,
you may be able to buy Medicare Parts A and B--or just Medicare
Part B--by paying monthly premiums. Also, you may be able to buy
Medicare Parts A and B if you are disabled and lost your
premium-free
Part A solely because you are working. (See page 34 for
more information.)
Enrollment in Medicare
If you are already getting Social Security or Railroad
Retirement benefit payments when you turn 65, you will
automatically get a Medicare card in the mail. The card will
show that you can get both Medicare Hospital Insurance (Part A)
and Medical Insurance (Part B) benefits. If you do not want
Part B, follow the instructions that come with the card.
The above process also applies when you have been a
disability beneficiary under Social Security or Railroad
Retirement for 24 months. A Medicare card will come in the
mail.
Some people do not automatically get a Medicare card. They
must file an application to get Medicare benefits. If you have
not applied for Social Security or Railroad Retirement
benefits, or if government employment is involved, or if you
have kidney disease, you must file an application for Medicare.
Check with Social Security if you are able to get Medicare
under the Social Security system or based on Medicare-covered
government employment; check with the Railroad Retirement
office if you are able to get Medicare under the Railroad
Retirement system.
If you must file an application for Medicare, you should
apply during your initial enrollment period, to avoid late
enrollment penalties under Medicare Part B (unless you qualify
for a special enrollment period as described on page 33). Your
initial enrollment period is a seven-month period that starts
three months before the month you first meet the requirements
for Medicare. If you do not sign up for Medicare during the
first three months of your initial enrollment period, there
will be a delay in starting your Part B coverage. Your coverage
will be delayed from one to three months after enrollment.
If you do not enroll for Medicare Part B at any time
during your initial enrollment period, you will not have
another chance to enroll until the next general enrollment
period. A general enrollment period is held each year from
January 1 through March 31 and if you enroll during this period
you will not be able to get Medicare until July of that year.
You may also be charged a premium penalty for late enrollment
(unless you qualify for a special enrollment period as
described on page 33).
The enrollment period requirements and penalties for late
enrollment described above for Part B also apply to people who
buy Part A. (See page 33 for more information about buying
Medicare Part A.)
Your Medicare Card
The Medicare card shows the Medicare coverage you
have--Hospital Insurance (Part A), Medical Insurance (Part B),
or both--and the date your protection started. If you do not
have both parts of Medicare, see page 33 for information on how
you can get the part you don't have.
Your Medicare card also shows your health insurance claim
number. Sometimes this claim number is referred to as your
Medicare number. The claim number usually has nine digits and
one or two letters. There may also be another number after the
letter. Your full claim number must always be included on all
Medicare claims and correspondence. When a husband and wife
both have Medicare, each receives a separate card and claim
number. Each spouse must use the exact name and claim number
shown on his or her card.
It is important that you remember to:
* Use your Medicare card only after the effective date shown
on it.
* Keep your card handy. And be sure to carry your card with
you whenever you are away from home.
* Always show your Medicare card when you receive services
that Medicare helps pay for.
* Always write your complete health insurance claim number
(including any letters) on all checks for Medicare
premium payments or any correspondence about Medicare.
Also, you should have your Medicare card available when
you make a telephone inquiry.
* Immediately ask Social Security to get you a new card if
you lose yours.
* Never let anyone else use your Medicare card.
Assistance for Low-Income Beneficiaries
Federal law requires that state Medicaid programs pay
Medicare costs for certain elderly and disabled people with low
incomes and very limited resources, described below. The
following is a general description only; rules may vary from
state to state.
Qualified Medicare Beneficiaries (QMB)
In general, you must meet these requirements:
* You must be entitled to Medic are Hospital Insurance (Part
A).
* Your annual income for 1992 must be at or below $7,050 for
one person and $9,430 for a family of two (amounts are
somewhat higher in Alaska and Hawaii).* Amounts for 1993
will be slightly higher than those for 1992.
* You cannot have resources such as bank accounts or stocks
and bonds worth more than $4,000 for an individual or
$6,000 for a couple. Your personal home, automobile,
burial plot, furniture, jewelry, or life insurance are not
counted, unless those items are of extraordinary value.
If you qualify as a QMB, your Medicare premiums,
deductibles and coinsurance will be covered.
* This amount is based on a percentage of the national
poverty guidelines plus an income disregard of $240.
Specified Low-income Medicare Beneficiaries (SLMB)
Beginning January 1, 1993, there is a new program for
certain low-income Medicare beneficiaries whose income is above
the level to qualify as a QMB, but whose income is below 110
percent of the national poverty guidelines. If you qualify as a
SLMB, Medicaid will pay your Medicare Part B premium only
($36.60 per month in 1993).
Where to Apply
If you think you may qualify for any of these benefits,
you should file an application at the state or local welfare,
social service or public health agency that serves people on
Medicaid. All of these agencies are state--not
federal--agencies.
If you need the telephone number for Medicaid, call
1-800-638-6833. Give the operator the name of your state and
explain that you want the Medicaid telephone number so you can
get information about these benefits.
Intermediaries and Carriers
The federal government contracts with private insurance
organizations called intermediaries and carriers to process
claims and make Medicare payments. Intermediaries handle
inpatient and outpatient claims submitted on your behalf by
hospitals, skilled nursing facilities, home health agencies,
hospices and certain other providers of services.
You will not usually need to get in touch with
intermediaries because Medicare pays most hospitals, skilled
nursing facilities, home health agencies, hospices and other
providers of services directly. But, if you have a question
about your Part A bill, ask someone who works at the facility
for help. If you cannot get an answer there, ask someone in the
billing office at the facility to help you get in touch with
the Medicare intermediary.
Carriers handle claims for services by doctors and
suppliers covered under Medicare's Part B program. If you have
questions about Medicare Part B claims, contact your Medicare
carrier. The addresses and phone numbers of carriers are on
pages 39 to 44.
If you want someone to contact Medicare for you, see "Your
Rights Under the Privacy Act," (page 5) for more information.
Peer Review Organizations
Peer Review Organizations (PROs) are groups of practicing
doctors and other health care professionals who are paid by the
federal government to review the care given to Medicare
patients. Each state has a PRO that decides, for Medicare
payment purposes, whether care is reasonable, necessary, and
provided in the most appropriate setting. PROs also decide
whether care meets the standards of quality generally accepted
by the medical profession. PROs have the authority to deny
payments if care is not medically necessary or not delivered in
the most appropriate setting.
PROs investigate individual patient complaints about the
quality of care and respond to:
* Requests for review of notices of noncoverage issued by
hospitals to beneficiaries; and
* Requests for reconsideration of PRO decisions by
beneficiaries, physicians, and hospitals.
The PRO will tell you in writing if the service you
got was not covered by Medicare. See page 12 for a discussion
of what is not covered by Medicare.
If you are admitted to a Medicare participating hospital,
you will receive An Important Message From Medicare which
explains your rights as a hospital patient and provides the
name, address and phone number of the PRO for your state. If
you are not given a copy of the message, be sure to ask for
one.
If you feel that you are improperly refused admission to a
hospital or that you are forced to leave the hospital too soon,
ask for a written explanation of the decision. Such a written
notice must fully explain how you can appeal the decision and
it must give you the name, address and phone number of the PRO
where your appeal or request for review can be submitted. (See
page 35 for further discussion of your appeal fights under
Medicare.)
Beneficiary Complaints
PROs are responsible for reviewing beneficiary complaints
about the quality of care provided by inpatient hospitals,
hospital outpatient departments and hospital emergency rooms;
skilled nursing facilities; home health agencies; ambulatory
surgical centers; and certain health maintenance organizations.
If you believe that you have received poor quality care
from one of these facilities, you may complain to the PRO. The
PRO will investigate written complaints from beneficiaries, or
their representatives, about the quality of Medicare services
received.
Your complaint must be in writing. If you wish, the PRO
will help you put your complaint in writing by taking the
information from you over the telephone and writing the
complaint. If someone other than the PRO makes a complaint for
you or on your behalf, you must give written permission for
that person to represent you in the complaint.
Medicare PROs for each state are listed on pages 45 to
49.
Your Right to Decide About Your Medical Care
Under a new Medicare law, when you are admitted to a
Medicare hospital or skilled nursing facility, get Medicare
home health care, or enroll in a Medicare-approved hospice or
health maintenance organization, you must be given written
information about your rights to make decisions about your
medical care.
Generally, you will be told about your fight to accept or
refuse medical or surgical treatment. You will also be told
about your fight to make--if you choose--an "advance
directive." An advance directive contains written instructions
about your choices for health care or naming someone to make
those choices for you. The instructions are to be used if you
are too sick or otherwise unable to talk. (The paper giving
your health care choices may be called a "living will" or "a
durable power of attorney for health care.")
You do not have to have an advance directive. But, if you
have one you can say "yes" in advance to treatment you want if
you get too sick to talk to your health care provider. You can
also say "no" in advance to treatment you don't want.
Laws governing advance directives vary from state to
state. Your treatment choices will depend on what is legal in
your state. You can ask health care professionals in your state
about the state's rules for living wills or durable powers of
attorney. You can also contact your local state's attorney's
office for this information.
Fraud and Abuse
Suspected Fraud Should be Reported
If you have reason to believe that a doctor, hospital, or
other provider of health care services is performing
unnecessary or inappropriate services, or is billing Medicare
for services you did not receive, you should immediately report
to the Medicare carrier or intermediary that handles your
claims (see page 3).
The routine waiver of deductibles and coinsurance by
doctors or suppliers of durable medical equipment is unlawful.
Coinsurance and deductible payments may be waived only after
careful consideration of a particular patient's financial
hardship. Therefore, if a doctor or supplier offers to waive
coinsurance or deductible payments, without having considered
your individual circumstances or when you have not asked to
have the payments waived, you should immediately report the.
offer to the Medicare carrier or intermediary.
Report to the Medicare Carrier or Intermediary First
Call the carrier or intermediary first when you suspect
fraud. Medicare carriers and intermediaries routinely look into
cases of possible fraud and will appreciate your alerting them
to your case. The carrier or intermediary will need to know the
exact nature of the wrongdoing you suspect, the date it
occurred, and the name and address of the party involved. Have
this information ready when you call. (The telephone number of
the Medicare intermediary or carrier is listed on the notice
explaining Medicare's decision on your Medicare claim. Medicare
carriers are also listed on pages 39 to 44.)
Calling For Further Help
If the Medicare carrier or intermediary does not respond
to your report of Medicare fraud or abuse, you may call the
Health Care Financing Administration (HCFA) hotline at
1-800-638-6833. There is no charge to you when you call this
number. The hotline operator will refer you to the appropriate
staff person at a HCFA regional office.
Be prepared to tell the HCFA regional office staff person:
* The exact nature of the wrongdoing you suspect, the date
it occurred, and the name and address of the party
involved.
* The name and location of the Medicare intermediary or
carrier you reported it to, and when you reported it.
* The name of any intermediary or carrier employee to whom
you spoke and what advice that person gave you.
Your Rights Under the Privacy Act
Under the Privacy Act all federal agencies must safeguard
information they collect about the people they serve.
When the Health Care Financing Administration (the agency
that administers the Medicare program) asks you to fill out
forms giving information about yourself to Medicare, we must:
* Explain why we are collecting the information.
* Tell you whom we plan to give it to.
* Tell you whether you must, by law, give us the
information.
When you give Medicare information, the Privacy Act allows
you to:
* Review your records for accuracy.
* Make corrections, if you believe there are errors.
* Know exactly what we will do with your records.
The Privacy Act also allows the government to verify the
information you give us, using computer matches with other
federal or state governments. If we do computer matches, we
must tell you that they take place and give you a chance to
protest our findings.
We include information about matches on all the forms you
fill out. We also put a notice in the Federal Register, which
is published by the federal government to notify the public of
official actions. Copies are available at many libraries. (A
computer-data match using Medicare, Internal Revenue Service
and Social Security information is discussed on page 11.)
Medicare Carriers and Intermediaries must follow Privacy
Act rules: These Medicare contractors may not discuss personal
information about you with your family members or others who
write or telephone on your behalf unless you give the
contractors written permission.
What Are Coordinated Care Plans?
More and more Medicare beneficiaries are joining
coordinated care plans. These coordinated care plans are
prepaid, managed care plans, most of which are health
maintenance organizations (HMOs) or competitive medical plans
(CMPs). Both HMOs and CMPs contract with Medicare and follow
the same contracting rules. In this handbook, HMOs will be used
to illustrate the benefits for both.
Many beneficiaries find that coordinated care plans are a
good way to get more health care for their dollar. HMOs provide
or arrange for all Medicare covered services, and generally
charge you fixed monthly premiums and only small co-payments.
This means that if you join a coordinated care plan and get all
of your services through the HMO, your out-of-pocket costs are
usually more predictable. Also, depending on your health needs,
those costs may be less than you would pay if you had to pay
the regular Medicare deductible and coinsurance amounts.
Coordinated care plans may also offer benefits not
covered by Medicare for little or no additional cost. Benefits
may include preventive care, dental care, heating aids and
eyeglasses.
Who Can Enroll in Coordinated Care Plans?
Most Medicare beneficiaries are eligible to enroll in
HMOs. HMOs cannot screen applicants to decide if they are
healthy, or delay coverage for pre-existing conditions. The
only enrollment criteria for Medicare HMOs are:
* You must be enrolled in Medicare Part B and continue to
pay the Part B premiums (you do not need to be able to get
Part A).
* You must live in the plan's service area.
* You cannot be receiving care in a Medicare-certified
hospice.
* You cannot have permanent kidney failure.
If you develop permanent kidney failure after joining a
coordinated care plan, the plan will provide, pay for, or
arrange for your care. If you choose to receive hospice care
after joining a coordinated care plan, the plan must inform you
about hospice services available in your area. Staff at the
coordinated care plan will explain how the hospice choice
affects your plan membership.
Joining a Coordinated Care Plan
To join a coordinated care plan, contact plans in your
area that have a contract with Medicare. All HMOs with Medicare
contracts have an advertised open enrollment period at least
once a year. Once you join, you may stay with the plan as long
as it continues to contract with Medicare. And you may return
to regular Medicare at any time.You can find out if there are
HMOs in your area that contract with Medicare by calling the
Health Care Financing Administration (HCFA) regional office
nearest you. Medicare Coordinated Care contact numbers are
listed in the box on page 7.
If you enroll in a coordinated care plan you will usually
be required to get all care from the plan. In most cases, if
you get services that are not authorized by the HMO (unless
they are emergency services or services you urgently need when
you are out of the plan's service area) neither the plan nor
Medicare will pay for the services.
When you join an HMO, be sure to read your membership
materials carefully to learn your fights and coverage.
Ending Enrollment in a Coordinated Care Plan
To end your enrollment in a coordinated care plan, send a
signed request to your plan or to your local Social Security or
Railroad Retirement Board office. You return to regular
Medicare the first day of the month following the month your
request is received by one of these offices. (If you leave a
coordinated care plan to return to regular Medicare and buy a
Medigap policy, you may have to wait for up to 6 months for the
new Medigap policy to cover any pre-existing condition.)
If You Have Problems
If you belong to a Medicare HMO and you are unhappy with
the quality of care, you can:
* Follow your HMO's grievance procedure, or
* Complain to your Peer Review Organization (PRO). PROs are
groups of practicing doctors and other health care
professionals under contract to Medicare to review the
care provided to Medicare patients (seepage 3).
If you have reason to believe that your Medicare HMO did
not give you necessary care, inappropriately ended your
enrollment, charged you an excessive premium, or falsified or
misrepresented information, you can:
* Write to the Office of Prepaid Health Care Operations and
Oversight, Room 4406 Cohen Building, 330 Independence
Ave., SW, Washington, DC 20201.
* Describe your problem. The Office will see that your case
is reviewed.
If you believe that your HMO has made an incorrect
decision on coverage of benefits or payment of a claim, you can
appeal--your appeal fights are similar to those provided under
traditional Medicare. (See page 36 for more information about
appeals.)
NOTE: A new Medicare supplement (Medigap) option is now
available in some states. It is a kind of coordinated care plan
called Medicare SELECT (see page 8 for more information).
If you need more information about Medicare and
coordinated care plans, you can get a copy of Medicare and
Coordinated Care Plans from the Consumer Information Center
(see inside back cover).
Regional Office Coordinated Care Contacts
Health Care Financing Administration staff at the offices
listed below can tell you if there are HMOs in your area that
contract with Medicare.
Boston: (Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island and Vermont) Beneficiary Services Branch
(617) 565-1232
New York: (New Jersey, New York, Puerto Rico and the Virgin
Islands) Carrier Operations Branch
(212) 264-8522
Philadelphia: (Delaware, District of Columbia,
Maryland, Pennsylvania, Virginia and West Virginia)
Beneficiary Services Branch
(215) 596-1332
Atlanta: (Alabama, North and South Carolina,
Florida, Georgia, Kentucky, Mississippi, and
Tennessee)
Beneficiary Services and HMO Branch
(404) 331-2549
Chicago: (Illinois, Indiana, Michigan, Minnesota, Ohio and
Wisconsin)
Beneficiary Services and HMO Branch
(312) 353-7180
Dallas: (Arkansas, Louisiana, New Mexico,
Oklahoma and Texas)
Beneficiary Services Branch
(214) 767-6401
Kansas City: (Iowa, Kansas, Missouri and
Nebraska)
Program Services Branch
(816) 426-2866
Denver: (Colorado, Montana, North and South
Dakota, Utah and Wyoming)
Beneficiary Services Branch
(303) 844-4024 ext 238
San Francisco: (American Samoa, Arizona,
California, Guam, Hawaii and Nevada)
Beneficiary Services Branch
(415) 744-3617
Seattle: (Alaska, Idaho, Oregon and
Washington)
Beneficiary Services Branch
(206) 553-0800
Medicare and Other Insurance
Buying Health Insurance to Supplement Medicare
Medicare provides basic protection against the cost of
health care, but it will not pay all of your medical expenses,
nor most long-term care expenses. For this reason, many private
insurance companies sell supplement (Medigap) insurance as well
as separate long-term care insurance. The federal government
does not sell or service such insurance.
Shopping for Medigap Insurance
If you are thinking about buying a new private insurance
policy or replacing an old policy to supplement your Medicare
protection or cover long-term care costs, you should shop
carefully. You can get a booklet, Guide to Health Insurance for
People with Medicare, to help you make Medicare supplement
decisions. (See box below for more information about the
guide.)
New Standardized Medigap Policies
Most states have adopted regulations limiting the sale of
Medigap insurance to no more than 10 standard policies. One of
the 10 is a basic policy offering a "core package" of benefits.
These standardized plans are identified by the letters A
through J. Plan A is the core package. The other nine plans
each have a different combination of benefits, but they all
include the core package. The basic policy, offering the core
package of benefits, is available in all states.
To find out what standardized policies are available in
your state, check with your state insurance department. The
telephone number of your state insurance department is probably
listed under "state agencies" in your telephone book. If not,
you can get a copy of the Guide to Health Insurance for People
with Medicare (see box below).
In most cases, if you already have a Medigap policy, you
may keep it but there are a few states where you must convert
your policy to one of the standard plans. In all cases, if you
buy a new policy, you will be required to choose a standardized
plan.
Open Enrollment Period for Medigap Policies
An open enrollment period for selecting Medigap policies
guarantees that for six months immediately following the
effective date of Medicare Part B coverage, people age 65 or
older cannot be denied Medigap insurance or charged higher
premiums because of health problems.
No matter how you enroll in Part B--whether by automatic
notification or through an initial, special or general
enrollment period--you are covered by the new guarantees if
both of the following are true:
* You are 65 or older and are enrolled in Medicare based on
age rather than disability.
* The date you get by adding six months to the effective
date for your Part B coverage (printed on your Medicare
card) is in the future. The date you get tells you when
your Medigap open enrollment ends.
NOTE: Even when you buy your Medigap policy in this open
enrollment period, the policy may still exclude coverage for
"pre-existing conditions" during the first six months the
policy is in effect. Pre-existing conditions are conditions
that were either diagnosed or treated during the six-month
period before the Medigap policy became effective.
Medicare SELECT
A new kind of Medigap insurance-available through 1994-has
been introduced in 15 states. It is called Medicare SELECT. The
difference between Medicare SELECT and regular Medigap
insurance is that a Medicare SELECT policy may (except in
emergencies) limit Medigap benefits to items and services
provided by certain selected health care professionals or may
pay only partial benefits when you get health care from other
health care professionals.
You can order a free copy of the Guide to health Insurance
for People With Medicare from the Consumer Information Center.
There is ordering information on the inside back cover of this
book. The guide:
* Explains how supplemental insurance works.
* Tells how to shop for Medigap insurance.
* Gives information on the new standard plans.
* Gives information on Medicare SELECT.
* Lists names, addresses and telephone numbers of state
insurance departments and state agencies on aging. Some of
these offices may have free counseling services available.
Insurers, including some HMOs, offer Medicare SELECT in
the same way standard Medigap insurance is offered. The
policies are required to meet certain federal standards and are
regulated by the states in which they are approved. The
premiums charged for Medicare SELECT policies are expected to
be lower than premiums for comparable Medigap policies that do
not have this selected-provider feature.
Medicare SELECT policies are permitted to be offered in
Alabama, Arizona, California, Florida, Illinois, Indiana,
Kentucky, Massachusetts, Minnesota, Missouri, North Dakota,
Ohio, Texas, Washington and Wisconsin. If you live in one of
these states, you can ask your state insurance department about
the Medicare SELECT policies that have been approved for sale
in the state.
Employment-related Retiree Coverage Instead of Medigap
Some retired people can get health coverage through their
former employer or union. This health coverage may supplement
Medicare but it is not Medigap insurance and does not have to
meet federal and state Medigap requirements. (See below for
rules about selling Medigap Insurance.)
Retiree coverage is usually provided free or at a greatly
reduced price and may be a good bargain. But the benefits may
not be adequate to serve as your supplement to Medicare. Does
your retiree plan have an "escape clause," so that benefits
might be changed? On the other hand, does your retiree plan
protect you from the preexisting condition restriction that
might be applied during the first six months under a Medigap
policy? Check carefully before you decide whether to stay with
your retiree coverage or buy a Medigap policy.
Medicaid Recipients
Low-income people who are eligible for Medicaid usually do
not need additional insurance. Medicaid pays for certain health
care benefits beyond those covered by Medicare, such as
long-term nursing home care. If you have Medigap insurance
purchased on or after November 5, 1991, and you become eligible
for Medicaid, you can ask that the Medigap benefits and
premiums be suspended for up to two years while you are covered
Medicaid. If you become ineligible for Medicaid benefits during
the two years, your Medigap policy is automatically
reinstituted if you give proper notice and begin paying
premiums again.
Coordinated Care Plans Instead of Medigap
Coordinated care plans that contract with Medicare are not
Medigap plans, but they can be an alternative to standard
Medigap insurance. (See page 6 for more information about
coordinated care plans.)
There are Rules for Selling Medigap Insurance
Both state and federal laws govern sales of Medigap
insurance. Companies or agents selling Medigap insurance must
avoid certain illegal practices. Federal criminal and civil
penalties (fines) may be imposed against any insurance company
or agent that knowingly:
* Sells you a health insurance policy that duplicates your
Medicare or Medicaid coverage, or any private health
insurance coverage you may have.
* Tells you that they are employees or agents of the
Medicare program or of any government agency.
* Makes a false statement that a policy meets legal
standards for certification when it does not.
* Sells you a Medigap policy that is not one of the 10
approved standard policies (after the new standards have
been put in place in your state).
* Denies you your Medigap open enrollment period by
refusing to issue you a policy, placing conditions on the
policy, or discriminating in the price of a policy because
of your health status, claims experience, receipt of
health care, or your medical condition.
* Uses the U.S. mail in a state for advertising or
delivering health insurance policies to supplement
Medicare if the policies have not been approved for sale
in that state.
If You Suspect Illegal Sales Practices
If you suspect that you have been the victim of illegal
sales practices, you should report these practices to your
state insurance department. States are responsible for the
regulation of insurance policies issued within their
boundaries. Because federal laws also govern Medigap sales
practices, you should also report the practices to the
appropriate federal officials.
Your state insurance department may be listed in your
telephone book. If not, you can get a copy of the booklet,
Guide to Health Insurance for People with Medicare (see box on
page 8).
To talk to federal officials about the suspected illegal
sales practices, you may call this number: 1-800-638-6833.
When Other Insurance Pays Before Medicare
If any of the following insurance situations applies to
you, please notify your doctor, hospital, and all other
providers of services. For more information about any of these
insurance situations, ask Social Security for a copy of
Medicare and Other Health Benefits. The publication is also
available free from the Consumer Information Center (see inside
back cover).
When You or Your Spouse Continue To Work
Medicare has special rules that apply to beneficiaries who
have employer group health plan coverage through their current
employment or the current employment of a spouse.
Group health plans of employers with 20 or more employees
are primary payers and Medicare is secondary payer for workers
age 65 or older, and workers' spouses age 65 or older. Group
health plans must offer these people the same health insurance
benefits under the same conditions offered to younger workers
and spouses. You and your spouse have the option to reject the
plan offered by the employer. If you reject the employer's
health plan, Medicare will remain the primary health insurance
payer. In that case, the employer's plan is not permitted to
offer you coverage that supplements Medicare covered services.
If your employer plan denies you coverage, offers you different
coverage, or pays benefits that are secondary to Medicare,
notify the carrier that handles your Medicare claims.
If You Are Disabled and Under Age 65
Medicare is the secondary payer for certain disabled
people who have premium-free Medicare Part A and are covered
under their employer's health plan or the employer health plan
of an employed family member. This secondary payer provision
applies to group health plans of employers that employ 100 or
more people. The secondary payer provision also applies to
group health plans of employers with fewer than 100 employees
if their employers are part of a multi-employer plan in which
at least one employer has 100 or more employees.
Other Situations Where Medicare is the Secondary Payer
If you have a work-related illness or injury, services
provided as treatment of that illness or injury should be
covered by workers' compensation or federal black lung
benefits. It is important that your Medicare claim form note
that the treatment is related to a work-related illness or
injury, even if the injury or illness occurred in the past.
Medicare is a secondary payer during a period (generally
18 months) for beneficiaries who have Medicare solely on the
basis of permanent kidney failure, if they have employer group
health plan coverage themselves or through a family member.
Medicare also serves as the secondary payer in cases where
no-fault insurance or liability insurance is available as the
primary payer.
Although Medicare benefits are secondary to benefits paid
by liability insurers, Medicare may make a conditional payment
if it receives a claim for services covered by liability
insurance. In those cases, Medicare may pay the claim; then,
when a liability settlement is reached, Medicare recovers its
conditional payment from the settlement amount.
If You Have or Can Get Both Medicare and Veterans Benefits
If you have or can get both Medicare and veterans
benefits, you may choose to get treatment under either program.
But, Medicare:
* Cannot pay for services you receive from Veterans Affairs
(VA) hospitals or other VA facilities, except for certain
emergency hospital services; and
* Generally cannot pay if the VA pays for VA-authorized
services that you get in a non-VA hospital or from a
non-VA physician.
Since July 1986, the VA has been charging coinsur-
ance payments to some veterans who have non-service connected
conditions for treatment in a VA hospital or medical facility,
or for VA-authorized treatment by nonVA sources. The VA charges
coinsurance payments when the veteran's income exceeds a
particular level. If the VA charges you a coinsurance payment
for VA-authorized care by a non-VA physician or hospital,
Medicare may be able to reimburse you, in whole or in part, for
your VA coinsurance payment obligation. (If you have Medigap
insurance, your Medigap policy may pay the VA coinsurance and
deductible obligations, even if Medicare cannot.)
NOTE: Medicare cannot reimburse you for VA coinsurance
payments for services furnished by VA hospitals and facilities,
unless the services are emergency inpatient or outpatient
hospital services. Then, the Medicare payment is subject to
Medicare deductible and coinsurance amounts.
If you have questions about whether the VA or Medicare
should pay for your doctor or other services covered under
Medicare Part B, contact your Medicare carrier. If you have
questions about whether the VA or Medicare should pay for
hospital or other services covered under Medicare Part A, ask
the provider of services to check with the Medicare
intermediary.
The Data Match
In 1989, Congress passed a; law that will help Medicare
get back an estimated $1 billion in taxpayer money. The law
enables Medicare to get accurate information about
beneficiaries' health insurance.
The law authorizes the Health Care Financing
Administration (the agency that administers the Medicare
program), the Internal Revenue Service, and the Social Security
Administration to share information about whether Medicare
beneficiaries or their spouses are working and whether they
have employment-related health insurance.
The process for sharing information from other agencies is
called the Data Match. The Data Match will help Medicare find
cases where another insurer should have paid first on Medicare
beneficiaries' health care claims. A designated Medicare
contractor will contact employers to confirm health insurance
coverage information. (For information about your fights under
the Data Match, see "Your Rights Under the Privacy Act,"
page 5.)
What Medicare Does Not Pay For
Custodial Care
Medicare does not pay for custodial care when that is the
only kind of care you need. Care is considered custodial when
it is primarily for the purpose of helping you with daily
living or meeting personal needs and could be provided safely
and reasonably by people without professional skills or
training. Much of the care provided in nursing homes to people
with chronic, long-term illnesses or disabilities is considered
custodial care. For example, custodial care includes help in
walking, getting in and out of bed, bathing, dressing, eating,
and taking medicine. Even if you are in a participating
hospital or skilled nursing facility, Medicare does not cover
your stay if you need only custodial care.
Care Not Reasonable and Necessary Under Medicare Program
Standards
Medicare does not pay for services that are not reasonable
and necessary for the diagnosis or treatment of an illness or
injury. These services include drugs or devices that have not
been approved by the Food and Drug Administration (FDA);
medical procedures and services performed using drugs or
devices not approved by FDA;* and services, including drugs or
devices, not considered safe and effective because they are
experimental or investigational.
* Some services are not covered by Medicare even when FDA
has approved the drug or device used.
If a doctor admits you to a hospital or skilled nursing
facility when the kind of care you need could be provided
elsewhere (for example, at home or in an outpatient facility),
your stay will not be considered reasonable and necessary, and
Medicare will not pay for your stay. If you stay in a hospital
or skilled nursing facility longer than you need to be there,
Medicare payments will end when inpatient care is no longer
reasonable and necessary.
If a doctor (or other practitioner) comes to treat
you---or you visit him or her for treatment--more often than is
medically necessary, Medicare will not pay for the "extra"
visits. Medicare will not pay for more services than are
reasonable and necessary for your treatment.
Medicare always bases decisions about what is reasonable
and necessary on professional medical advice.
Services Medicare Does Not Pay For
Medicare, by law, cannot pay for certain services. These
include services performed by immediate relatives or members of
your household, and services paid for by another government
program. If you have a question about whether Medicare pays for
a particular service, ask your Medicare carrier. (See pages 39
to 44 for the name and telephone number of your carrier.)
Limitation of Liability
Under Medicare law you will not be held responsible for
payment of the cost of certain health care services for which
you were denied Medicare payment if you did not know or you
could not reasonably be expected to know (for example, you had
not received a written notice) that the services were not
covered by Medicare. This provision is called limitation of
liability and is often referred to as a "waiver of liability."
This protection from financial liability applies only when the
care was denied because it was one of the following: Custodial
care.
Not "reasonable and necessary" under Medicare program
standards for diagnosis or treatment.
* For home health services, the patient was not homebound or
not receiving skilled nursing care on an intermittent
basis.
* The only reason for the denial is that, in error, you were
placed in a skilled nursing facility bed that was not
approved by Medicare.
This limitation of liability provision does not apply to
Medicare Part B services provided by a non-participating
physician or supplier who did not accept assignment of the
claim. However, in certain situations Medicare law will protect
you from paying for services provided by a non-participating
physician on a non-assigned basis that are denied as "not
reasonable and necessary." If your physician knows or should
know that Medicare will not pay for a particular service as
"not reasonable and necessary," he or she must give you written
notice--before performing the service--of the reasons why he
or she believes Medicare will not pay. The physician must get
your written agreement to pay for the services. If you did not
receive this notice, you are not required to pay for the
service. If you did pay, you may be entitled to a refund. (This
written notice is not an official Medicare. determination. If
you disagree with it, you may ask your doctor to submit a claim
for payment to get an official Medicare determination.)
Medicare Hospital Insurance (Part A)
What Medicare Part A Includes
Medicare Part A helps pay for four kinds of medically
necessary care:
1) Inpatient hospital care.
2) Inpatient care in a skilled nursing facility following a
hospital stay.
3) Home health care.
4) Hospice care.
There is a limit on how many days of hospital or skilled
nursing facility care Medicare helps pay for in each benefit
period. But, your Part A protection is renewed every time you
start a new benefit period. (Benefit periods are described
below.)
Skilled nursing facility care is the only type of nursing
home care that Medicare covers. Medicare does not pay for care
that is primarily custodial. (See pages 17 and 20 for more
about custodial care.)
Benefit Periods
A benefit period is a way of measuring your use of
services under Medicare Part A. Your First benefit period
starts the first time you receive inpatient hospital care after
your Hospital Insurance begins. A benefit period ends when you
have been out of a hospital or other facility primarily
providing skilled nursing or rehabilitation services for 60
days in a row (including the day of discharge). If you remain
in a facility (other than a hospital) that primarily provides
skilled nursing or-rehabilitation services, a benefit period
ends when you have not received any skilled care there for 60
days in a row. After one benefit period has ended, another one
will start whenever you again receive inpatient hospital care.
There is no limit to the number of benefit periods you can
have for hospital and skilled nursing facility care. However,
special limited benefit periods apply to hospice care (see page
19).
Here are two examples of how the benefit period works:
Example 1: Ms. Jones enters the hospital on January 5. She
is discharged on January 15. She has used 10 days of her first
benefit period. Ms. Jones is not hospitalized again until July
20. Since more than 60 days elapsed between her hospital stays,
she begins a new benefit period, her Part A coverage is
completely renewed, and she will again pay the hospital
deductible. (The hospital deductible is explained on page 15.)
Example 2: Ms. Smith enters the hospital on August 14. She
is discharged on August 24. She also has used 10 days of her
first benefit period. However, she is then readmitted to the
hospital on September 20. Since fewer than 60 days elapsed
between hospital stays, Ms. Smith is still in her first benefit
period and will not be required to pay another hospital
deductible. This means that the first day of her second
admission is counted as the eleventh day of hospital care in
that benefit period. Ms. Smith will not begin a new benefit
period until she has been out of the hospital (and has not
received any skilled care in a skilled nursing facility) for 60
consecutive days.
How Medicare Pays for Part A Services
Medicare Part A helps pay for most but not all of the
services you receive in a hospital or skilled nursing facility
or from a home health agency or hospice program. There are
covered services and noncovered services under each kind of
care. Covered services are services and supplies that Part A
pays for.
Hospitals, skilled nursing facilities, home health
agencies and hospices are called "providers" under the Medicare
Part A program. Providers submit their claims directly to
Medicare--you cannot submit claims for their services. The
provider will charge you for any part of the Part A deductible
you have not met and any coinsurance payment you owe. Providers
cannot require you to make a deposit before being admitted for
inpatient care that is or may be covered under Part A of
Medicare.
When a hospital, skilled nursing facility, home health
agency, or hospice sends Medicare a Part A claim for payment,
you get a Notice of Utilization that explains the decision
Medicare made on the claim. This notice is not a bill. If you
have any questions about the notice, get in touch with the
people who sent you the notice.
When You Are a Hospital Inpatient
Medicare Part A helps pay for inpatient hospital care if
all of the following four conditions are met:
1) A doctor prescribes inpatient hospital care for treatment
of your illness or injury.
2) You require the kind of care that can be provided only in
a hospital.
3) The hospital is participating in Medicare.*
4) The Utilization Review Committee of the hospital, a Peer
Review Organization or an intermediary does not disapprove
your stay.
* Under certain conditions, Medicare helps pay for
emergency inpatient care you receive in a
non-participating hospital.
If you meet these four conditions, Medicare will help pay
for up to 90 days of medically necessary inpatient hospital
care in each benefit period.**
** Medicare pays for only limited inpatient care in a
psychiatric hospital (see page 16). The hospital can tell
you about these limits.
During 1993, from the first day through the 60th day in a
hospital during each benefit period, Part A pays for all
covered services except the first $676. This is called the
inpatient hospital deductible. (A deductible is an amount you
owe before Medicare begins paying for services and supplies
covered by the program.) The hospital may charge you the
deductible only for your first admission in each benefit
period. If you are discharged and then readmitted before the
benefit period ends, you do not have to pay the deductible
again.
From the 61st through the 90th day in a hospital during
each benefit period, Part A pays for all covered services
except for $169 a day. This daily amount is called coinsurance.
The hospital charges you the $169.
Hospital reserve days (explained below) can help with your
expenses if you need more than 90 days of inpatient hospital
care in a benefit period.
Medicare Part A does not pay for the services of doctors
and certain other practitioners, even though you receive these
services in a hospital. Instead, those services are covered
under Medicare Part B. (A description of Medicare Part B begins
on page 21.)
Major services covered under Part A when you are a
hospital inpatient:
* A semiprivate room (two to four beds in a room).
* All your meals, including special diets.
* Regular nursing services.
* Costs of special care units, such as intensive care or
coronary care units.
* Drugs furnished by the hospital during your stay.
* Blood transfusions furnished by the hospital during your
stay. (See page 16 for information about coverage of
blood.)
* Lab tests included in your hospital bill.
* X-rays and other radiology services, including radiation
therapy, billed by the hospital.
* Medical supplies such as casts, surgical dressings, and
splints.
* Use of appliances, such as a wheelchair.
* Operating and recovery room costs.
* Rehabilitation services, such as physical therapy,
occupational therapy, and speech pathology services.
Some services not covered under Part A when you are a
hospital inpatient:
* Personal convenience items that you request such as a
telephone or television in your room.
* Private duty nurses.
* Any extra charges for a private room unless it is
determined to be medically necessary.
NOTE: If you disagree with a decision on the amount
Medicare will pay on a claim or whether services you receive
are covered by Medicare, you always have the fight to appeal
the decision (see page 35).
Hospital Inpatient Reserve Days
Medicare helps pay for your care in a hospital for up to
90 days in each benefit period. Medicare Part A also includes
an extra 60 hospital days you can use if you have a long
illness and have to stay in the hospital for more than 90 days.
These extra days are called reserve days.
You have only 60 reserve days in your lifetime. For
example, if you use 8 reserve days in your first hospital stay
this year, the next time you visit a hospital you will have
only 52 reserve days left to use, whether or not you have a new
benefit period.
You can decide when you want to use your reserve days.
After you have been in the hospital 90 days, you can use all or
some of your 60 reserve days if you wish.
If you do not want to use your reserve days, you must tell
the hospital in writing, either when you are admitted to the
hospital, or at any time afterwards up to 90 days after you are
discharged. If you use reserve days and then decide that you
did not want to use them, you must request approval from the
hospital to get them restored.
During 1993, Medicare Part A pays for all covered services
except $338 a day for each reserve day you use. You are
responsible for paying this $338.
All Medigap plans pay some part of hospital bills after
you have used all your reserve days. (See page 8 for more
information about Medigap insurance.)
Coverage of Blood Under Part A
Part A helps pay for blood (whole blood or units of packed
red blood cells), blood components, and the cost of blood
processing and administration. If you receive blood as an
inpatient of a hospital or skilled nursing facility, Part A
will pay for these blood costs, except for any nonreplacement
fees charged for the first three pints of whole blood or units
of packed red cells per calendar year. (The nonreplacement fee
is the amount that some hospitals and skilled nursing
facilities charge for blood that is not replaced.)
You are responsible for the nonreplacement fees for the
first three pints or units of blood furnished by a hospital or
skilled nursing facility. If you are charged nonreplacement
fees, you have the option of either paying the fees or having
the blood replaced. If you choose to have the blood replaced,
you can either replace the blood personally or arrange to have
another person or an organization replace it for you. A
hospital or skilled nursing facility cannot charge you for any
of the first three pints of blood you replace or arrange to
replace. (If you have already paid for or replaced blood under
Medicare Part B during the calendar year, you do not have to
meet those costs again under Medicare Part A. See page 21 for
an explanation of coverage of blood under Medicare Part B.)
Care in a Psychiatric Hospital
Part A helps pay for no more than 190 days of inpatient
care in a participating psychiatric hospital in your lifetime.
Once you have used these 190 days, Part A does not pay for any
more inpatient care in a psychiatric hospital.
Also, a special role applies if you are in a participating
psychiatric hospital at the time your Part A starts. Social
Security can give you more information.
Care Outside the United States
Medicare generally does not pay for hospital or medical
services outside the United States. (Puerto Rico, the U.S.
Virgin Islands, Guam, American Samoa, and the Northern Mariana
Islands are considered part of the United States.)
If you are planning to travel outside the United States,
you may want to buy special short-term health insurance for
foreign travel. If you have other health insurance in addition
to Medicare, check to see if health care in a foreign country
is covered under your policy.
There are rare emergency cases where Medicare can pay for
care in Canada or Mexico |