The Medicare Handbook
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. Also, Medicare can sometimes
pay if a
Mexican or Canadian hospital is closer to your
home than the
nearest U.S. hospital that can provide the care
you need. If
you get emergency treatment in a Canadian or Mexican
hospital
or if you live near a Canadian or Mexican hospital,
ask someone
who works at the hospital about Medicare coverage,
or have the
hospital help you contact the Medicare intermediary.
Care in a Christian Science Sanatorium
Medicare Part A helps pay for inpatient
hospital and
skilled nursing facility services you receive
in a
participating Christian Science sanatorium if
it is operated or
listed and certified by the First Church of Christ,
Scientist,
in Boston. (However, Medicare Part B will not
pay for the
practitioner.)
The Prospective Payment System
Medicare pays for most inpatient hospital
care under the
Prospective Payment System (PPS). Under PPS, hospitals
are paid
a predetermined rate per discharge for inpatient
services
furnished to Medicare beneficiaries. The predetermined
rates
are based on payment categories called Diagnosis
Related
Groups, or DRGs. In some cases, the Medicare payment
will be
more than the hospital's costs; in other cases,
the payment
will be less than the hospital's costs. In special
cases,
where costs for necessary care are unusually high
or the length
of stay is unusually long, the hospital receives
additional
payment. But even if Medicare pays the hospital
less than the
cost of your care, you do not have to make up
the difference.
It is important to remember that the
PPS system does not
change your Medicare Part A protection as described
in this
handbook. PPS does not determine the length of
your stay in the
hospital or the extent of care you receive. The
law requires
participating hospitals to accept Medicare payments
as payment
in full, and those hospitals are prohibited from
billing the
Medicare patient for anything other than the applicable
deductible and coinsurance amounts, plus any amounts
due for
noncovered items or services such as television,
telephone or
private duty nurses.
Skilled Nursing Facility Care
Medicare Part A can help pay for certain
inpatient care in
a Medicare-participating skilled nursing facility
following a
hospital stay. Your condition must require daily
skilled
nursing or skilled rehabilitation services which,
as a
practical matter, can only be provided in a skilled
nursing
facility, and the skilled care you receive must
be based on a
doctor's orders.
What is a Skilled Nursing Facility?
A skilled nursing facility is a specially
qualified
facility that specializes in skilled care. It
has the staff and
equipment to provide skilled nursing care or skilled
rehabilitation services and other related health
services.
Skilled nursing care means care that can only
be performed by,
or under the supervision of, licensed nursing
personnel.
Skilled rehabilitation services may include such
services as
physical therapy performed by, or under the supervision
of, a
professional therapist.
Most nursing homes in the United States
are not skilled
nursing facilities that participate in Medicare.
In some
facilities, only certain portions participate
in Medicare. If
you are not sure whether a facility participates
in Medicare as
a skilled nursing facility, ask someone in the
facility's
business office. If staff at the facility cannot
tell you, ask
Social Security to check with the Health Care
Financing
Administration.
When Can Medicare Pay?
Medicare Part A can help pay for your
care in a
Medicare-participating skilled nursing facility
if you meet all
of these five conditions:
1) Your condition requires daily skilled
nursing or skilled
rehabilitation services which, as a practical
matter, can
only be provided in a skilled nursing facility.
2) You have been in a hospital at least three
days in a row
(not counting the day of discharge) before
you are admitted
to a participating skilled nursing facility.
3) You are admitted to the facility within
a short time
(generally within 30 days) after you leave
the hospital.
4) Your care in the skilled nursing facility
is for a
condition that was treated in the hospital,
or for a
condition that arose while you were receiving
care in the
skilled nursing facility for a condition
which was treated
in the hospital.
5) A medical professional certifies that
you need, and you
receive, skilled nursing or skilled rehabilitation
services
on a daily basis.
All five conditions must be met. Remember,
you must need
skilled nursing care or skilled rehabilitation
services on a
daily basis. Part A will not pay for your stay
if you need
skilled nursing or rehabilitation services only
occasionally,
such as once or twice a week, or if you do not
need to be in a
skilled nursing facility to get skilled services.
Also,
Medicare will not pay for your stay if you are
in a skilled
nursing facility mainly because you need custodial
care.
Skilled Care or Custodial Care?
The only type of "nursing home"
care Medicare helps pay
for is skilled nursing facility 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 the patient with daily living
or meeting
personal needs, and could be provided safely and
reasonably by
people Without professional skills or training.
For example,
custodial care includes help in walking, getting
in and out of
bed, bathing, dressing, eating and taking medicine.
When your stay in a skilled nursing facility
is covered by
Medicare, Part A helps pay for a maximum of 100
days in each
benefit period, but only if you need daily skilled
nursing care
or rehabilitation services for that long.
If you leave a skilled nursing facility
and are readmitted
within 30 days, you do not have to have a new
three day stay in
the hospital for your care to be covered. If you
have some of
your 100 days left and you need skilled nursing
or
rehabilitation services on a daily basis for further
treatment
of a condition treated during your previous stay
in the
facility, Medicare will help pay.
In each benefit period, Part A pays for
all covered
services for the first 20 days you are in a skilled
nursing
facility. During 1993, for days 21 through 100,
Part A pays for
all covered services except for $84.50 a day.
You may be
charged up to this daily coinsurance amount by
the skilled
nursing facility.
Medicare Part A does not cover your doctor's
services while
you are in a skilled nursing facility. Medicare
Part B covers
doctors' services. (A description of Medicare
Part B begins on
page 21.)
Major services covered under Part A when you
are in a skilled
nursing facility:
* A semiprivate room (two to four beds in
a room).
* All your meals, including special diets
furnished by the
facility.
* Regular nursing services.
* Physical, occupational, and speech therapy.
* Drugs furnished by the facility during your
stay.
* Blood transfusions furnished during your
stay. (See page
16 for information about coverage of blood.)
* Medical supplies such as splints and casts
furnished by
the facility.
* Use of appliances such as a wheelchair
furnished by the
facility.
Some services not covered under Part A when
you are in a
skilled nursing facility:
* Personal convenience items that you request
such as a
television in your room.
* Private duty nurses.
* Any extra charges for a private room, unless
it is
determined to be medically necessary.
Rules That Protect You
Skilled nursing facilities cannot require
you to pay a
deposit or other payment as a condition of admission
to the
facility unless it is clear that services are
not covered by
Medicare.
If you are already an inpatient in a skilled
nursing
facility and the staff at the facility decides
you no longer
need the level of skilled care covered by Medicare,
they must
notify you immediately. If you disagree with this
decision, the
facility must submit your claim at your request
to Medicare for
an official Medicare decision on coverage. The
facility may not
require you to pay a deposit until Medicare issues
its
decision. You must pay for any coinsurance while
your claim is
being processed, and for any services which are
never covered
by Medicare.
Complaints and Appeals
If you want to complain about a skilled
nursing facility's
treatment of patients or other conditions that
concern you, you
can contact the state survey agency. Each skilled
nursing
facility can give you the telephone number and
address of the
state survey agency if you ask for it. You can
also look at a
copy of the skilled nursing facility's latest
certification
survey report. The survey report will tell you
the results of
the state survey agency's review of how well the
agency thinks
the facility followed the rules about patient's
rights, safety
and quality of care.
Also, 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).
Home Health Care
If you need skilled health care in your
home for the
treatment of an illness or injury, Medicare pays
for covered
home health services furnished by a participating
home health
agency. A home health agency is a public or private
agency that
specializes in giving skilled nursing services
and other
therapeutic services, such as physical therapy,
in your home.
(A hospital or other facility that mainly provides
skilled
nursing or rehabilitation services cannot be considered
your
home.)
Medicare pays for home health visits only
if all four of
the following conditions are met:
1) The care you need includes intermittent
skilled nursing
care, physical therapy, or speech therapy.
2) You are confined to your home (homebound).
3) You are under the care of a physician
who determines
you need home health care and sets up a home
health
plan for you.
4) The home health agency providing services
participates
in Medicare.
Once all four of these conditions are
met, either Medicare
Part A or Medicare Part B will pay for all medically
necessary
home health services. When you no longer need
intermittent
skilled nursing care, physical therapy, or speech
therapy,
Medicare will pay for home health services if
you continue to
need occupational therapy.
Medicare home health services do not include
coverage for
general household services such as laundry, meal
preparation,
shopping, or other home care services furnished
mainly to
assist people in meeting personal, family, or
domestic needs.
To determine whether you can get services
under the
Medicare home health benefit, ask your physician
to refer you
to a Medicare participating home health agency.
The home health
agency will evaluate your case and tell you whether
you meet
the requirements for Medicare coverage. Home health
agencies
should not charge for this evaluation.
Home health services covered by Medicare:
* Part-time or intermittent skilled nursing
care. (This can
include eight hours of reasonable and necessary
care per
day for up to 21 consecutive days--or longer
in certain
circumstances.)
* Physical therapy.
* Speech therapy.
If you need intermittent skilled nursing
care, or
physical or speech therapy, Medicare also pays
for:
* Occupational therapy.
* Part-time or intermittent services of
home health aides.
* Medical social services.
* Medical supplies.
* Durable medical equipment (80 percent
of approved amount).
Home health services not covered by Medicare.
* 24-hour-a-day nursing care at home.
* Drugs and biologicals.
* Meals delivered to your home.
* Homemaker services.
* Blood transfusions.
Medicare pays the full approved cost of
all covered home
health visits. You may be charged only for any
services or
costs that Medicare does not cover. However, if
you need
durable medical equipment, you are responsible
for a 20 percent
coinsurance payment for the equipment. (See page
26 for more
information about durable medical equipment.)
The home health agency will submit the
claim for payment.
You do not have to send in any bills yourself.
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).
Hospice Care
A hospice is a public agency or private
organization that
is primarily engaged in providing pain relief,
symptom
management and supportive services to terminally
ill people.
Hospice care is a special type of care
for people who are
terminally ill. It includes both home care and
inpatient care,
when needed, and a variety of services not otherwise
covered
under Medicare. Under the Medicare hospice benefit,
Medicare
pays for services every day and also permits a
hospice to
provide appropriate custodial care, including
homemaker
services and counseling.
Medicare Part A helps pay for hospice
care if all three of
these conditions are met:
1) A doctor certifies that the patient is
terminally ill.
2) The patient chooses to receive care from
a hospice
instead of standard Medicare benefits for
the terminal
illness.
3) Care is provided by a Medicare-participating
hospice
program.
Special benefit periods apply to hospice
care. Part A pays
for two 90-day periods, followed by a 30-day period,
and--when
necessary--an extension period of indefinite duration.
If a
beneficiary cancels hospice care during one of
the first three
benefit periods, any days left in that period
are lost, but the
remaining benefit period(s) are still available,
And, a
beneficiary may disenroll from the hospice during
any benefit
period, return to regular Medicare coverage, then
later
re-elect the hospice benefit if another benefit
period is
available.
Two Benefit Period Examples:
* Mr. Jones cancelled his hospice care at
the end of 59 days
during his first 90-day benefit period. He
lost the 31
remaining days of the first 90-day period.
But if he wants
to, he can choose hospice care again. He
still has a
90-day period, a 30-day period, and the indefinite
extension period.
* Ms. Smith cancelled hospice care during
her final
extension period. She cannot use the Medicare
hospice
benefit again.
There are no deductibles under the hospice
benefit. The
beneficiary does not pay for Medicare-covered
services for the
terminal illness, except for small coinsurance
amounts for
outpatient drugs and inpatient respite care.
The patient is responsible for five percent
of the cost of
outpatient drugs or $5 toward each prescription,
whichever is
less. For inpatient respite care, the patient
pays five percent
of the Medicare-allowed rate (approximately $4.48
per day in
1993). The rate varies slightly depending on the
area of the
country.
Respite care under the hospice program
is a shortterm
inpatient stay in a facility. The Medicare beneficiary's
inpatient stay gives temporary relief--a respite--to
the person
who regularly assists with home care. Each inpatient
respite
care stay is limited to no more than five days
in a row.
While receiving hospice care, if a patient
requires
treatment for a condition not related to the terminal
illness,
Medicare continues to help pay for all necessary
covered
services under the standard Medicare benefit program.
Services covered by Part A when provided by
a hospice:
* Nursing services.
* Doctors' services.
* Drugs, including outpatient drugs for
pain relief and
symptom management.
* Physical therapy, occupational therapy
and speechlanguage
pathology.
* Home health aide and homemaker services.
* Medical social services.
* Medical supplies and appliances.
* Short-term inpatient care, including respite
care.
* Counseling.
The Medicare Part A hospice benefit does
not pay for
treatments other than for pain relief and symptom
management of
a terminal illness. Regular Medicare can usually
help pay for
treatments not related to the terminal illness.
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 right
to appeal
the decision (see page 35).
Medicare Medical Insurance (Part B)
What Medicare Part B Includes
Medicare Part B helps pay for:
* Doctors' services.
* Outpatient hospital care.
* Diagnostic tests.
* Durable medical equipment.
* Ambulance services.
* Many other health services and supplies that
are not
covered by Medicare Part A.
The following sections tell you more about
these different
kinds of care, the services that are and are not
covered by
Medicare Part B, and what part of your medical
expenses
Medicare will pay.
Deductible and Coinsurance Amounts Under Part
B
The Annual Deductible
You must pay the first $100 in approved
charges for
covered medical expenses in 1993. This is called
the Medicare
Part B annual deductible. You need to meet this
$100 deductible
only once during the year, and the deductible
can be met by any
combination of covered expenses. You do not have
to meet a
separate deductible for each different kind of
covered service
you receive.
The Blood Deductible
You must pay any nonreplacement fees charged
for the first
three pints or units of blood and blood components
you use each
year. (The nonreplacement fee is the amount that
some
practitioners and facilities charge for blood
that is not
replaced.) This is called the Medicare Part B
blood deductible.
After you have replaced or paid for the first
three pints of
blood and you have met the $100 annual deductible,
Medicare
will pay 80 percent of the approved amount for
blood, starting
with the fourth pint. (If you have already paid
for or replaced
some units of blood under Medicare Part A during
the calendar
year, you do not have to pay for or replace that
number of
units again under Medicare Part B.)
Coinsurance
After you pay the annual deductible, you
will owe a share
of the Medicare-approved amount for most services
and supplies.
This share is called coinsurance. Usually, your
coinsurance
share is 20 percent of the Medicare-approved amount.
Medicare determines the approved amount
for each service
you receive. If your services were provided "on
assignment,"
you pay only the coinsurance (see page 28 for
an explanation of
assignment).
If your services were not provided "on
assignment," and
the charges for your services were more than the
Medicare-approved amount, you usually owe the
Medicare
coinsurance plus certain charges above the Medicare-approved
amount. (See "Medicare Approved Amounts"
on page 29.) There are
limits on the amount your doctor can charge you.
NOTE: This explanation of your deductible
and coinsurance
amounts describes Medicare's payment system for
most services
covered by Medicare Part B. In cases where payment
for services
is handled in a different way, you will be given
an explanation
along with the description of services covered.
(You will find
more information about how Medicare pays Part
B claims in the
section beginning on page 28.)
Doctors' Services Covered By Medicare Part
B
Medicare Part B helps pay for covered
services you receive
from your doctor in his or her office, in a hospital,
in a
skilled nursing facility, in your home, or any
other location.
Major doctors' services covered by Medicare
Part B:
* Medical and surgical services, including
anesthesia.
* Diagnostic tests and procedures that are
part of your
treatment.
* Radiology and pathology services by doctors
while you are
a hospital inpatient or outpatient.
* Treatment of mental illness. (Medicare
payments for
treatment are limited; see page 27)
* Other services such as:
-- X-rays.
-- Services of your doctor's office nurse.
-- Drugs and biologicals that cannot
be
self-administered.
-- Transfusions of blood and blood components,
-- Medical supplies.
-- Physical/occupational therapy and
speech pathology
services.
Some doctors' services not covered by Medicare
Part B:
* Routine physical examinations, and tests
directly related
to such examinations (except some Pap smears
and
mammograms, see page 25).
* Most routine foot care and dental care.
* Examinations for prescribing or fitting
eyeglasses or
hearing aids.
* Immunizations (except pneumococcal pneumonia
vaccinations
or immunizations required because of an injury
or
immediate risk of infection, and hepatitis
B for certain
persons at risk).
* Cosmetic surgery, unless it is needed because
of
accidental injury or to improve the function
of a
malformed part of the body.
Types of Doctors
Most doctors' services are furnished by
a doctor of
medicine or a doctor of osteopathy. Other "physicians"
that can
furnish some covered services include chiropractors,
doctors of
podiatric medicine (podiatrists), doctors of dental
surgery or
of dental medicine (dentists), and doctors of
optometry
(optometrists).
Chiropractors' Services
Medicare helps pay for only one kind of
treatment
furnished by a licensed chiropractor: manual manipulation
of
the spine to correct a subluxation that is demonstrated
by
X-ray. Medicare Part B does not pay for any other
diagnostic or
therapeutic services, including Xrays, furnished
by a
chiropractor.
Podiatrists' Services
Medicare Part B helps pay for any covered
services of a
licensed podiatrist to treat injuries and diseases
of the foot.
Examples of common problems include ingrown toenails,
hammer
toe deformities, bunion deformities and heel spurs.
Medicare generally does not pay for routine
foot care such
as cutting or removal of corns and calluses, trimming
of nails,
and other hygienic care. But, Medicare does help
pay for some
routine foot care if you are being treated by
a medical doctor
for a medical condition affecting your legs or
feet (such as
diabetes or peripheral vascular disease) which
requires that
the routine care be performed by a podiatrist
or by a doctor of
medicine or osteopathy.
Dentists' Services
Medicare Part B generally does not pay
for care in
connection with the treatment, filling, removal,
or replacement
of teeth; root canal therapy; surgery for impacted
teeth; or
other surgical procedures involving the teeth
or structures
directly supporting the teeth. However, Medicare
does help pay
for services of a dentist in certain cases when
the medical
problem is more extens | 
